Tuberculo5i5  in  Massachusetts 


Prepared  by  the  Massachusetts  State  Committee  for  the  International 

Congress  on  Tuberculosis,  held  in  Washington,  D.  C, 

September  21  to  October  12,  1908. 


«5 


Edited  by 
EDWIN   A,   LOCKE,   A.M..  M.D. 


^ 


WRIGHT  &   POTTER   PRINTING   COMPANY 
18  Post  Office  Square,  Boston 

1908 


674 


Preface. 

This  volume  is  published  by  the  Massachusetts  State 
Committee,  as  a  supplement  to  the  general  exhibit  prepared 
for  the  International  Congress  on  Tuberculosis,  in  accord- 
ance with  the  provisions  of  the  following  resolve,  and  with 
the  approval  of  the  State   Board  of  Health  :  — 

Chapter  140,  Resolves  of  1908. 

Resolve  to   provide  for  an   exhibit  at  the   international  congress  on 

tuberculosis. 
Resolved,  That  there  be  allowed  and  paid  out  of  the  treasury  of  the  common- 
wealth a  sum  not  exceeding  thirty-eight  hundred  dollars,  to  be  expended  under 
the  direction  of  the  state  board  of  health  for  the  expense  of  collection,  trans- 
portation, installation,  care  and  return  of  a  suitable  state  exhibit  at  the  inter- 
national congress  on  tuberculosis  to  be  held  in  the  city  of  Washington  in  the 
District  of  Columbia  from  September  twenty-first  to  October  twelfth,  inclusive, 
in  the  year  nineteen  hundred  and  eight.     [Approved  June  12,  1908. 

While  designed  primarily  for  general  distribution  at  the 
Congress,  the  Committee  has  had  in  mind  its  special  appli- 
cation to  the  many  problems  in  the  tuberculosis  work  arising 
within  the  Commonwealth.  The  past  few  years  have  wit- 
nessed such  a  general  awakening  throughout  the  State  and 
the  development  of  so  many  activities  along  various  lines 
that  it  is  difficult  to  get  a  proper  perspective.  The  object 
of  this  memoir  is  therefore  a  practical  one:  namely,  to  make 
available  for  every  section  of  the  State  information  regarding 
the  work  done  in  every  other,  and  to  present  the  most  essen- 
tial features  of  the  general  movement.  With  this  object  in 
view,   a    special  effort    has    been    made    to    give    in    consider- 


60,'?4:8r^ 


iv  PREFACE. 

able  detail  an  account  of  the  most  important  work,  and  to 
reproduce  photographs  and  plans  of  the  various  types  of 
institution. 

The  lack  of  accurate  and  complete  mortality,  and,  to  a 
far  greater  degree,  morbidity  statistics  regarding  tuberculosis 
in  the  State  has  made  it  impossible  to  include  any  statis- 
tical investigation  of  the  conditions  in   Massachusetts. 


Contents. 


PAGE 

List  of  Contributors,  .........  ix 

Introduction,    .........  .  .  xi 

Frederick  I.  Knight,  M.D. 

Chapter  I. 

The  State  and  its  Part  in  the  Tuberculosis  Movement,       ....  i 

Arthur  T.  Cabot,  M.D. 

Chapter  II. 

The  Work  of  the  State  Board  of  Health, lo 

Charles  Harrington,  M.D. 

Chapter  HI. 
The  Work  of  the  State  inspectors  of  Health,    .         .         .         .         .         .         i8 

William  C.  Hanson,  M.D. 

Chapter  IV. 

Sanitation  of  Clothing  Factories  and  Tenement-house  Workrooms,      .         .        28 

Harry  Linenthal,  M.D. 

Chapter  V. 
Bovine  Tuberculosis  in  Massachusetts,     .......        37 

Austin  Peters,  M.R.C.V.S. 

Chapter  VI. 
The  Origin  and  Growth  of  the  Sanatorium  Treatment  of  Pulmonary  Tuber- 
culosis in  Massachusetts,  ........        65 

Vincent  Y.  Bowditch,  M.D. 

Chapter  VH. 

Tuberculosis  in  the  State  Institutions  for  the  Insane,         ....        81 

Charles  W.  Page,  M.D. 

Chapter  VHI. 
Tuberculosis  in  the  Prisons  of  Massachusetts,  ......        94 

Joseph  I.  McLaughlin,  M.D. 


VI  CONTENTS. 


Chapter  IX. 

PAGE 

The  Treatment  of  Surgical  Tuberculosis  in  Massachusetts,  ...        99 

Edward  H.  Bradford,  M.D. 

Chapter  X. 

The  Work  of  the  Communities  throughout  the  State,         .         .         .         .115 

Edwin  A.  Locke,  M.D. 

Chapter  XI. 

The  Work  of  the  Anti-Tuberculosis  Societies  in  the  State,  .  .  .       135 

Arthur  K.  Stone,  M.D.,  and  Walter  E.  Kreusi,  B.S. 

Chapter  XII. 
Experimental  Researches  in  Tuberculosis,  with  Special  Reference  to  Eti- 
ology, Pathology  and  Immunity,      .  .         .         .         .         .158 

Theobald  Smith,  M.D. 

Chapter  XIII. 
Out-of-door  Sleeping  in  New  England,     .......       175 

Charles  S.  Millet,  M.D. 

Chapter  XIV. 
On  an  Apparent  Connection  between  Polluted  Public  Water  Supplies  and 

the  Mortality  from  Pulmonary  Tuberculosis,  .  .  .181 

William  T.  Sedgwick,  Ph.D.,  and  Scott  MacNutt,  S.B. 

Chapter  XV. 

The  Relation  of  the  Industries  of  Worcester  to  Tuberculosis,      .  .  .       187 

Albert  C.  Getchell,  M.D. 

Chapter  XVI. 

Tuberculosis  among  the  Granite  Workers  of  Quincy,  .         .         .         •       '93 

John  A.  Gordon,  M.D. 

Appendix. 
List  of  Articles  on  Tuberculosis  by  Massachusetts  Authors,         .  .  .       203 

Massachusetts  Committee  of  the  International  Tuberculosis  Congress,  .       221 


List  of  Illustrations. 


State  Sanatorium  at  Rutland, 


Frontispiece 

FACING 


State  Hospital  at  Tewksbury.  —  Hospital  for  Consumptives, 

Hospital  for  Consumptive  Men  at  Tewksbury. —  Floor  Plan, 

The  Martin's  Brook  Sanatorium. —  Front  Elevation  and  Floor  Plan  of  Open 
Shack,     .......... 

The  Martin's  Brook  Sanatorium.  —  Floor  Plan  of  Closed  Pavilion, 

Typical  Tailor  Shop,  where  Contract  Work  is  done,     . 

Corner  of  Shop  where  High-grade  Custom  Coats  are  pressed. 

Clothing  Factory.  — Showing  ideal  Conditions, 

Sharon  Sanatorium  at  Sharon.  —  From  the  Southwest, 

Sharon  Sanatorium  at  Sharon.  —  Sleeping  Balcony,    . 

State  Sanatorium  at  Rutland.  —  Block  Plan,     .... 

The  Millet  Sanatorium  at  East  Bridgewater,       .... 

The  Millet  Sanatorium  at  East  Bridgewater. — -Showing  Shacks, 

Danvers  Insane  Hospital  at  Hathorne.  —  Special  Ward  Building  for  Tuber 
culous  Patients,         ........ 

Danvers  Insane  Hospital  at  Hathorne.  —  Special  Ward  Building  for  Tuber 
culous  Patients,  showing  Interior  of  Ward, 

Danvers  Insane  Hospital  at  Hathorne.  —  Special  Ward  Building  for  Tuber 
culous  Patients,  showing  Veranda,      .  ... 

Hospital  Prison  for  Consumptives  at  Rutland,   .... 

Hospital  Prison  for  Consumptives  at  Rutland. —  Floor  Plan, 

Good  Samaritan  Hospital  and  Day-camp  at  Boston,   . 

Convalescent  Home  of  the  Children's  Hospital  at  Wellesley  Hills.  —  Showing 
Shack  Unit,     .......... 

State  Hospital-school  for  Crippled  Children,  at  Canton.  —  Showing  Unit, 

State  Hospital-school  for  Crippled  Children,  at  Canton. —  Recreation  and 
Education  Centre  of  Unit,  ...... 

State  Hospital-school  for  Crippled  Children,  at  Canton. —  Interior  of  Educa- 
tion and  Recreation  Centre,      ...... 

State  Hospital-school  for  Crippled  Children,  at  Canton. —  Interior  of  Dor- 
mitory,   .......... 

Day-camp  at  Cambridge,  ....... 

Day-camp  at  Cambridge. —  Floor  Plan,    ..... 


29 

30 
32 
66 
68 
72 
77 
78 

84 

86 

90 

97 
98 
102 

107 
109 


"3 

"3 
117 
116 


Viii  LIST    OF    ILLUSTRATIONS. 


FACING 
PAGE 


es, 


Chart  I.  —  Showing  Death-rate  from  Pulmonary  Tuberculosis  in  Boston  from 

1846  to  1906 "8 

Boston  Consumptives'   Hospital  at   Mattapan.  —  Elevation   Plan  of  Ward 

Building '21 

Boston  Consumptives'  Hospital  at  Mattapan.  —  Floor  Plan  of  Ward  Build- 
ing  '20 

Boston  Consumptives' Hospital  at  Mattapan.  —  Day-camp,  .  .  .122 
Boston  Consumptives'  Hospital  at  Mattapan.  —  Floor  Plan  of  Day-camp,  .  122 
Boston  Consumptives'  Hospital  at  Mattapan.  —  Dining-room  of  Day-camp,  .  122 
Boston  Consumptives'  Hospital  at  Mattapan.  —  Front  Elevation  of  Cottage 

Ward 124 

Boston  Consumptives'  Hospital  at  Mattapan.  —  Floor  Plan  of  Cottage  Ward,  1 24 
Plan  of  Organization  of  the  Municipal  Campaign  in   Boston,  showing  the 


Relation  of  Various  Institutions  caring  for  Consumptiv 
Bulletins  posted  by  the  Boston  Consumptives'  Hospital, 
Cullis  Consumptives'  Home  at  Dorchester, 
Tuberculosis  Exhibit  of  the  Boston  Association, 
Tuberculosis  Exhibit  of  the  Boston  Association, 

Day-camp  of  1907  at  Mattapan.  —  Maintained  by  the  Boston  Association, 
Children's  Day-camp  at  Parker  Hill.  —  Maintained  by  the  Boston  Association 
Sleeping  Balcony  used  by  Class  Patient  in  Haverhill, 
Polling  Booths  used  for  Consumptives  at  Haverhill,    .... 

Day-camp  at  Holyoke,    ......... 

Original  Sleeping  Balcony  in  Hanover.  —  Used  since  June,  1898, 

The  Millet  Sanatorium  at  East  Bridgewater.  —  Shack  used  for  Treatment  of 

Tuberculosis,    ....... 

The  Millet  Sanatorium.  —  Floor  Plan  of  Shack, 

Map  of  Massachusetts,  showing  Distribution  of  Population,  etc..  Following  page  223 


126 
130 
141 

'43 

142 
144 
144 
149 

'5' 
152 
176 

'79 
.78 


Contributors. 

Vincent  Y.  Bowditch,  M.D.,  Boston. 

Medical  Director  of  the  Sharon  Sanatorium;   formerly  Medical  Director  of 
the  State  Sanatorium  at  Rutland. 

Edward  H.  Bradford,  M.D.,  Boston. 

Professor  of  Orthopedic  Surgery  in  the  Harvard  Medical  School. 

Arthur  T.  Cabot,  M.D.,  Boston. 

Chairman  of  the  State  Commission  on  Hospitals  for  Consumptives. 

Albert  C.  Getchell,  M.D.,  Worcester. 

Member  of  the  State  Commission  on  Hospitals  for  Consumptives  and  of 
the  Board  of  Trustees  of  the  State  Sanatorium  at  Rutland. 

John  A.  Gordon,  M.D.,  Quincy. 
Charles  Harrington,  M.D.,  Boston. 

Professor  of  Hygiene  in  the  Harvard  Medical  School;  Secretary  of  the  Mas- 
sachusetts State  Board  of  Health. 

William  C.  Hanson,  M.D.,  Boston. 

Assistant  to  the  Secretary  of  the  State  Board  of  Health. 

Frederick  I.  Knight,  M.D.,  Boston. 

Consulting  Physician  to  the  Sharon  Sanatorium  and  the  Free  Hospital  for 
Consumptives. 

Walter  E.  Kreusi,  B.S.,  Boston. 

Secretary  of  the  Boston  Association  for  the  Relief  and  Control  of  Tuber- 
culosis. 

Harry  Linenthal,  M.D.,  Boston. 

State  Inspector  of  Health,  District  No.  5. 

Edwin  A.  Locke,  M.D.,  Boston. 

Chief  of  Staff  of  the  Boston  Consumptives'  Hospital. 

Scott  MacNutt,  S.B.,  Boston. 

Massacl  usetts  Institute  of  Technology. 

Joseph  I.  McLaughlin,  M.D.,  Boston. 

Physician  to  the  State  Prison,  Charlestown. 


X  CONTRIBUTORS. 

Charles  S.  Millet,  M.D.,  Brockton. 

Medical  Director  of  the  jMillet  Sanatorium,  East  Bridgewater. 

Charles  W.  Page,  M-.D.,  Danvers. 

Superintendent  and   Physician  at  the  Danvers  Insane  Hospital,  Hathorne. 

Austin  Peters,  M.R.C.V.S.,  Boston. 

Chief  of  the  Cattle  Bureau  of  the  Massachusetts  State  Board  of  Agriculture. 

William  T.  Sedgwick,  Ph.D.,  Boston. 

Professor  of  Biology  at  the  Massachusetts  Institute  of  Technology. 

Theobald  Smith,  M.D.,  Boston. 

George  Fabyan  Professor  of  Comparative  Pathology  in  the  Harvard  Med- 
ical School. 

Arthur  K.  Stone,  M.D.,  Boston. 

Vice-President  of  the   Boston  Association  for  the  Relief  and  Control  of 
Tuberculosis;  Visiting  Physician  to  the  Good  Samaritan  Hospital. 


INTRODUCTION, 

Frederick    I.    Knight,    M.D. 

The  former  high  mortality  from  consumption  in  Massachusetts 
and  other  New  England  States  is  well  known.  It  was  at  first 
attributed  to  the  severity  of  the  climate,  but  later  rather  to 
various  unhygienic  conditions,  such  as  vitiated  air,  poor  food 
and  damp  soil,  and  before  the  discovery  of  the  active  agent  of 
the  disease  the  mortality  had  been  greatly  diminished  by  im- 
proved hygiene. 

Having  had  such  experience,  it  was  not  unnatural,  when  the 
value  of  closed  sanatoria  for  the  treatment  of  incipient  tuber- 
culosis had  been  established,  that  Massachusetts  should  be  the 
first  State  to  erect  such  an  institution.  The  establishment  of 
sanatoria,  public  and  private,  has  served  not  only  to  arrest  the 
disease  in  many  patients  subjected  to  their  strict  regime,  but 
has  been  of  incalculable  worth  in  teaching  preventative  measures 
to  many  others.  Unfortunately,  the  reputation  of  the  sanatorium 
treatment  is  suffering  somewhat  at  present  in  this  State,  as  in 
others,  from  exaggerated  claims  which  were  made  for  it,  and  on 
account  of  rather  frequent  relapses  of  patients  (discharged  as 
cases  of  arrested  disease)  after  returning  to  their  unhygienic 
homes  and  work.  Supervision  of  patients  discharged  from  sana- 
toria, and,  as  far  as  possible,  the  amelioration  of  adverse  condi- 
tions of  their  lives,  must  be  a  part  of  the  great  movement  against 
tuberculosis.  The  gradual  inuring  of  patients  to  work,  and  in- 
struction in  some  healthy  occupation  before  leaving  the  sanatoria, 
is  a  step  in  the  right  direction,  especially  since  idleness,  when  long 
maintained,  has  been  well  called  the  curse  of  the  consumptive. 

Since  the  discovery  of  the  tubercle  bacillus  and  the  infectious- 


Xii  INTRODUCTION. 

ness  of  the  disease,  the  importance  of  special  hospitals  for  patients 
with  advanced  tuberculosis,  who  cannot  be  properly  cared  for  at 
home,  is  self-evident,  and  this  State  has  authorized  the  erection 
of  three  such,  and  the  city  of  Boston  one. 

But  the  care  of  cases  of  tuberculosis,  incipient  or  advanced,  is 
only  a  small  part  of  the  work. 

When  the  discovery  of  the  tubercle  bacillus  was  announced, 
the  thought  came  of  the  eradication  of  the  disease,  but  the  task 
seemed  almost  too  great  to  be  undertaken,  considering  the  almost 
universal  dissemination  of  the  bacilli;  but  it  was  soon  realized 
that  the  same  building  up  of  the  human  system  which  would 
arrest  the  disease  when  present,  would  also  prevent  its  inception 
in  the  uninfected,  and  a  movement  was  begun  not  only  to  prevent, 
as  far  as  possible,  the  transmission  of  the  germ,  but  also  to  put 
the  individual  in  such  condition  of  health  as  to  prevent  its  develop- 
ment. So  the  movement  is  not  merely  a  fight  to  combat  the 
disease  in  those  already  affected,  or  even  to  annihilate  the  germ, 
but  to  make  the  people  immune  to  it.  When  there  are  no  sus- 
ceptible subjects,  the  germ  will  cease  to  exist. 

The  present  report  will  show  how  fully  the  people  of  this  State 
appreciate  the  magnitude  and  at  the  same  time  the  hopefulness 
of  the  task.  They  feel  that  every  case  of  tuberculosis  discovered 
should  be  followed  to  its  home,  not  only  to  care  for  the  patient, 
and  insure,  as  far  as  possible,  against  his  infection  of  others,  but 
also  to  do  everything  possible  to  make  others  immune  to  the 
disease.  To  accomplish  this,  special  organizations  have  been 
effected  in  Boston  and  other  cities,  special  committees  have  been 
appointed  from  every  district  of  the  Massachusetts  Medical  So- 
ciety, and  the  State  has  been  divided,  largely  on  account  of  the 
tuberculosis  problem,  into  fifteen  health  districts,  with  an  in- 
spector in  each,  to  insure  as  far  as  possible  the  hygiene  of  factories, 
workshops  and  tenements,  as  well  as  of  the  families  of  the  working- 


INTRODUCTION.  XIU 

men.  The  Boston  Consumptives'  Hospital  Trustees  have  under- 
taken the  most  thorough  following  up  of  Boston  cases. 

All  these  special  agencies  are  obtaining  more  and  more  the  active 
co-operation  of  our  health  boards,  State  and  local,  and  of  all  our 
charitable  institutions  which  have  to  do  with  the  poor  and  their 
homes. 

How  important  all  these  means  are,  and  how  efficient  they  have 
already  become,  may  be  judged  from  the  chapters  which  follow. 
In  reading  these  chapters,  one  must  feel  that  Massachusetts,  with 
her  special  sanatoria,  hospitals,  dispensaries,  laboratories,  day- 
camps,  prospective  out-door  schools,  her  control  of  bovine  tuber- 
culosis, and  the  combined  action  of  many  general  and  special 
bodies  in  following  up  the  disease,  has  made  a  most  gratifying 
start  in  the  struggle  against  this  disease. 


Chapter  I. 

THE   STATE   AND   ITS    PART  IN   THE   TUBERCULOSIS 

MOVEMENT. 

Arthur  T.  Cabot,  M.D. 

The  State  of  Massachusetts  exercises  supervision  over  tuber- 
culous patients,  and  has  endeavored  to  prevent  and  control 
tuberculosis  by  means  of  the  following  organizations  and  insti- 
tutions. The  list  covers  the  efforts  made  under  direct  state  con- 
trol and  also  organizations  which  are  not  local  but  extend  their 
activity  over  the  whole  Commonwealth. 

1.  The  State  Board  of  Health. 

2.  The  State  Board  of  Agriculture. 

3.  The  State  Board  of  Education. 

4.  The  State  Sanatorium  at  Rutland. 

5.  The  special  wards  in  connection  with  other  state  hospitals 
and  reformatory  institutions. 

6.  The  Associated  Committees  of  the  Massachusetts  Medical 
Society  for  the  Prevention  and  Control  of  Tuberculosis. 

7.  The  Commission  to  investigate  Measures  for  the  Relief  of 
Consumptives,  appointed  in  1906. 

8.  The  Massachusetts  Commission  on  Hospitals  for  Consump- 
tives, appointed  in  1907. 

9.  The  state  inspectors  of  health. 

10.  The  Federation  of  Women's  Clubs. 

1.  The  Siaie  Board  of  Health  has  been  active  in  combating 
tuberculosis  from  the  time  of  its  foundation,  in  1869.  An  account 
of  its  work  is  given  in  the  succeeding  chapter. 

2.  The  Cattle  Bureau  of  the  State  Board  of  Agriculture  has  general 
supervision  over  the  inspection  of  cattle  throughout  the  State, 


2  TUBERCULOSIS    IN    MASSACHUSETTS. 

and  power  to  properly  dispose  of  tuberculous  cattle  that  are  dis- 
covered by  or  reported  to  it. 

3.  The  State  Board  of  Education  is  now,  in  compliance  with 
recent  legislation,  issuing  a  pamphlet  on  the  tuberculosis  problem, 
for  the  purpose  of  informing  the  teachers  throughout  the  State 
as  to  the  essential  facts  about  this  disease,  to  the  end  that  they 
may  present  them  intelligently  to  their  pupils. 

4.  The  State  Sanatorium  at  Rutland,  for  the  treatment  of  tuber- 
culosis in  the  early  stages,  was  built  in  the  year  1896,  and  was  the 
first  state  sanatorium  in  the  United  States.  It  is  fully  described 
in  another  chapter,  and  is  only  briefly  mentioned  here  as  one  of 
the  most  important  and  successful  agencies  through  which  the 
State  has  sought  to  curtail  the  ravages  of  tuberculosis. 

5.  The  various  state  hospitals  for  the  insane,  the  pauper  poor 
and  the  penal  institutions  have  separated  the  tuberculous  from 
the  other  inmates,  and  in  many  cases  have  built  specially  designed 
wards  for  them.  The  most  important  of  these  is  at  the  State 
Hospital  at  Tewksbury,  where  accommodations  for  about  two 
hundred  tuberculous  poor  are  provided  in  isolated,  well-equipped 
buildings. 

Many  of  the  patients  in  the  State  Hospital  are  advanced  cases, 
which  are  brought  there  from  poor  and  crowded  quarters  in 
which  they  would  be  certain  to  spread  infection.  In  this  way 
excellent  preventive  work  has  been  accomplished  where  this  work 
has  been  of  the  greatest  importance. 

The  following  is  a  list  of  state  institutions  thus  providing  for 
the  isolation  of  tuberculous  inmates:  State  Hospital,  Tewksbury; 
State  Farm,  Bridgewater;  State  Hospital-School  for  Crippled 
Children,  Canton;  Danvers  Insane  Hospital,  Hathorne;  West- 
borough  Insane  Hospital,  Westborough;  Medfield  Insane  Asylum, 
Medfield  Junction;  Massachusetts  School  for  the  Feeble-minded, 
Waverley. 


CABOT.  3 

At  Palmer,  the  Taunton  Insane  Asylum  and  the  State  Hospital 
at  Foxborough  there  are  no  consumptive  wards,  but  care  is  taken 
to  separate  such  cases  and  to  provide  for  open-air  treatment. 

6.  Associated  Committees  of  the  Massachusetts  Medical  Society. 
—  In  1905  the  various  district  medical  societies  of  which  the 
Massachusetts  Medical  Society  is  made  up  appointed  committees 
to  consider  the  question  of  the  control  and  prevention  of  tuber- 
culosis within  the  State. 

In  some  districts  these  committees  were  small,  consisting  of 
from  three  to  five  members,  while  in  others  they  were  larger, 
and,  seeking  to  fully  represent  the  various  localities,  they  com- 
prised members  from  all  of  the  considerable  cities  and  towns  in 
the  district. 

It  soon  became  evident  that  the  enlargement  of  the  committees 
was  adding  to  the  efficiency  of  the  work,  as  it  led  to  a  more 
thorough  understanding  of  the  conditions  and  needs  of  the  various 
localities.  The  districts  having  small  committees  were  urged  to 
enlarge  them  by  adding  members  from  all  of  the  large  places  that 
were  unrepresented.  This  has  been  done  in  most  of  the  districts, 
so  that  at  the  present  time  these  committees  comprise  one  hun- 
dred and  ninety-four  members  from  one  hundred  and  fifty-six 
cities  and  towns. 

To  promote  uniformity  of  action  and  of  interest  these  commit- 
tees were  called  together  at  the  first  annual  meeting  of  the  state 
society  after  their  appointment,  and  they  then  voted  to  join  in 
an  organization  to  be  called  "The  Associated  Committees  of  the 
Massachusetts  Medical  Society  for  the  Relief  and  Control  of 
Tuberculosis."  They  elected  a  chairman  and  secretary  and  voted 
to  publish  a  report  each  year. 

The  activities  of  the  committees  during  the  first  year  were  di- 
rected to  studying  the  conditions  as  they  existed  throughout  the 
State,  and  a  brief  abstract  of  their  reports  was  published  in  the 


4  TUBERCULOSIS    IN    MASSACHUSETTS. 

first  annual  report.  In  this  report  the  suggestion  was  made  that 
efforts  should  be  directed  especially  to  four  principal  objects, 
namely :  first,  perfecting  registration ;  second,  procuring  thorough 
and  general  disinfection  after  the  death  or  removal  of  a  tubercu- 
lous patient;  third,  the  formation  of  anti-tuberculosis  associations; 
fourth,  procuring  hospitals  for  advanced  cases. 

During  that  year  a  compulsory  registration  law  was  put  on  the 
statutes.  An  act  providing  for  the  establishment  of  three  sana- 
toria for  tuberculous  patients  was  passed  by  the  same  Legislature. 
The  Associated  Committees  did  their  part  in  promoting  this 
legislation.  The  success  of  their  efforts  to  procure  thorough  dis- 
infection has  varied  greatly  in  different  localities.  In  some  com- 
munities the  practice  of  disinfection  has  been  greatly  improved, 
but  it  will  evidently  be  a  matter  needing  constant  attention  until 
the  community  is  educated  to  understand  its  importance  and 
demands  it. 

The  members  of  the  Associated  Committees  have  been  active 
and  successful  in  promoting  the  formation  of  voluntary  anti- 
tuberculosis societies.  In  1905  Boston,  Cambridge,  Springfield 
and  Worcester  were  the  only  cities  in  the  State  having  societies 
of  this  sort. 

During  this  year  Dr.  J.  C.  Pitta,  a  Portuguese  physician  of 
New  Bedford,  established  an  anti-tuberculosis  society  called  the 
"Portuguese  League  of  Assistance  to  the  Consumptives,"  among 
his  fellow-countrymen  in  New  Bedford. 

Just  prior  to  the  formation  of  the  committee  in  the  Middlesex 
North  District  Medical  Society,  in  1906,  an  anti-tuberculosis  as- 
sociation was  formed  in  Lowell,  with  the  assistance  of  Mr.  A.  M. 
Wilson,  the  efficient  secretary  of  the  Boston  Association. 

In  1906-07  anti-tuberculosis  societies  were  formed  under  the 
auspices  of  the  local  committee  of  the  Associated  Committees  in 
Haverhill,   Salem,    Holyoke,   Walpole,    Brookline,    Brockton   and 


CABOT.  5 

Fitchburg.    Similar  associations  have  been  formed  in  Lawrence, 
Lynn,  Northampton,  Pittsfield  and  Qinton  during  the  past  year. 

Besides  these  associations  in  larger  towns  there  are  other  places 
in  which  smaller  committees  for  anti-tuberculosis  work  have  been 
formed;  physicians  have  started  classes  for  the  instruction  of 
tuberculous  patients,  and  visiting  nurses  have  been  taught  and 
urged  to  give  especial  care  in  the  oversight  of  their  tuberculous 
cases.  The  local  boards  of  health  have  been  stimulated  and  sup- 
ported by  the  medical  profession  in  carrying  out  preventive  meas- 
ures. 

The  first  day-camp  was  inaugurated  by  the  Boston  Association, 
and  proved  so  successful  in  economically  dealing  with  the  tuber- 
culous poor  that  the  same  treatment  has  been  adopted  in  a  number 
of  places,  including  Cambridge,  Springfield,  Lowell,  Holyoke, 
Brookline,  Fitchburg,  New  Bedford  and  Salem. 

These  are  some  of  the  more  tangible  results  already  brought 
about  or  greatly  aided  by  the  Associated  Committees. 

An  equally  important  effect  has  been  that  produced  upon  the 
medical  profession  itself.  This  organization  within  the  Massa- 
chusetts Medical  Society  was  formed  to  bring  the  medical  men 
throughout  the  State  into  the  closest  possible  touch  with  the  cam- 
paign against  tuberculosis,  to  make  them  acquainted  with  the 
work  done  in  other  places  and  to  arouse  their  interest  and  their 
confidence  in  the  hopefulness  of  this  endeavor.  It  is  plain  that  it 
is  largely  through  the  practising  physicians  that  the  patients  must 
be  reached  and  placed  in  proper  surroundings  for  a  cure.  By 
them  they  must  be  taught  how  to  get  well  and  how  to  avoid  spread- 
ing the  disease.  It  is  necessary,  then,  that  the  physicians  be  fully 
informed  as  to  the  various  agencies  that  may  be  asked  to  assist 
them  in  curing  their  consumptive  patients.  They  must  know 
where  to  obtain  and  how  to  use  the  various  appliances  for  sleeping 
in  the  open  air,  as  plans  for  cheap  sleeping  balconies,  and  should 


6  TUBERCULOSIS   IN    MASSACHUSETTS. 

be  informed  of  the  success  which  has  attended  this  form  of  treat- 
ment, in  order  that  they  may  themselves  be  encouraged  to  use  it 
and  may  have  arguments  to  convince  their  patients  that  it  is  worth 
the  trouble  and  expense. 

They  should  also  be  intimately  acquainted  with  the  various 
sanatoria  for  consumptives,  in  order  that  they  may  judge  of  the 
appropriate  place  for  a  particular  case,  and  may  also  know  how 
most  easily  to  obtain  his  admission.  The  Associated  Committees, 
with  their  members  scattered  throughout  the  State,  are  an  efificient 
means  of  spreading  this  information,  and  of  keeping  alive  the  in- 
terest of  their  communities  in  anti-tuberculosis  work. 

It*is  to  be  expected  that,  as  it  becomes  more  and  more  widely 
recognized  that  consumption  in  the  incipient  stage  is  curable,  the 
physicians,  becoming  more  and  more  interested  in  finding  their 
cases  while  still  curable,  will  make  greater  efforts  to  detect  the 
disease  in  its  early  stages,  and  will  avail  themselves  more  fully 
of  opportunities  to  have  sputum  examinations  made  in  doubtful 
cases. 

The  Associated  Committees  have  already  had  a  good  effect  in 
helping  the  medical  men  in  Massachusetts  to  co-operate  in  the 
important  field  of  preventive  medicine. 

7.  Commission  to  investigate  Measures  for  the  Relief  of  Con- 
sum-ptives.  —  In  the  spring  of  1906,  in  accordance  with  a  legisla- 
tive resolve,  Governor  Guild  appointed  a  Commission  to  investigate 
measures  for  the  relief  of  consumptives  and  sites  for  state  hospi- 
tals for  consumptives.  After  a  careful  study  of  the  conditions 
throughout  the  State  this  Comrrtission  embodied  its  observations 
and  recommendations  in  a  report,  of  which  the  following  is  a 
summary:  — 

I.  As  to  the  number  of  persons  in  the  Commonwealth  who  are  suffering  from 
pulmonary  tuberculosis,  or  consumption:  — 

That  the  total  number  of  cases  of  pulmonary  tuberculosis  reported  to  the  Com- 


CABOT.  7 

mission  is  7,779;  of  these,  6,376  are  private  patients  of  physicians  who  answered 
the  circular  letter  sent  out  by  the  Commission,  and  1,403  are  in  either  private  or 
public  institutions  located  in  the  State.  The  number  of  incipient  cases  reported 
is  2,792;  the  number  of  advanced,  2,339;  ^nd  the  number  of  far  advanced, 
2,648. 

2.  As  to  appropriate  and  available  sites  for  a  hospital  or  hospitals  for  the  treat- 
ment of  such  sufferers:  — 

That  many  appropriate  and  available  sites,  such  as  have  been  described  in  the 
text,  can  easily  be  found  in  every  county  and  in  the  neighborhood  of  nearly  every 
municipality  in  the  State. 

3.  As  to  the  probable  cost  to  the  Commonwealth  of  erecting  and  maintaining 
hospitals  adequate  for  such  treatment:  — 

That  the  probable  cost  of  erecting  such  hospitals  would  be  about  $500  per  bed; 
and  of  maintenance,  from  $7  to  §9  per  week  per  patient. 

4.  As  to  the  advisability  of  the  undertaking  by  the  Commonwealth  of  the  care 
and  treatment  of  such  sufferers,  the  Commission  advises:  — 

That  the  statutes  relating  to  the  public  health  be  amended  by  inserting  the 
word  "tuberculosis"  after  the  words  "scarlet  fever,"  in  sections  49,  50  and  52, 
chapter  75,  Revised  Laws;  and  also  by  inserting  the  word  "tuberculosis"  after 
the  word  "  smallpox  "  and  after  the  word  "  diphtheria,"  in  sections  1  and  2,  chapter 
213,  Acts  of  1902. 

That  section  i,  chapter  165,  Acts  of  1906,  relating  to  the  prohibition  of  expec- 
toration in  certain  public  places,  be  amended  by  inserting  the  words  "  in  any 
mill  or -factory,  or  in  any  hall  of  any  tenement  building  occupied  by  five  or  more 
families,  or  in  any  school  building,"  after  the  words  "or  music  hall." 

That  the  State  erect  three  hospitals  for  the  treatment  of  tuberculosis,  to  be 
devoted  principally  to  the  treatment  of  cases  in  the  advanced  stages  of  the  disease; 
one  of  these  hospitals  to  be  located  somewhere  in  the  Connecticut  Valley,  another 
in  the  northeastern  part  and  a  third  in  the  southeastern  part  of  the  State;  each 
of  the  hospitals  to  be  built  to  accommodate  not  over  one  hundred  and  fifty  patients. 
That  proper  legislation  be  enacted  so  as  to  provide  for  medical  inspectors. 
(Signed)  Henry  P.  Walcott,  M.D.,  Chairman. 

Charles  H.  Adams. 
Jeffrey  R.  Brackett. 
Charles  H.  Porter. 
(Signed)  Adams  S.  MacKnight,  M.D. 

Charles  S.  Millet,  M.D.,  Secretary. 

8.  Massachusetts  Commission  on  Hospitals  for  Consumptives.  — 
The  Legislature  of  1907,  after  considering  tiie  above  report,  passed 
an  act  to  provide  for  establishing  three  sanatoria  for  tuberculous 


8  TUBERCULOSIS    IN    MASSACHUSETTS. 

patients,  and  appropriated  $300,000  for  this  object.  Pursuant  to 
this  act  the  Governor  appointed  the  following  Commission: 
Charles  H.  Adams,  Dr.  Arthur  T.  Cabot  (chairman),  Alvah 
Crocker,  Dr.  Albert  C.  Getchell,  William  C.  Godfrey,  Mrs.  Sylvia 
B.  Knowlton,  Dr.  William  D.  McFee  and  Jeremiah  Smith,  Jr. 

This  Commission  was  appointed  in  July,  1907,  organized  on 
September  i,  and  has  since  that  time  been  actively  at  work  in- 
vestigating sites  and  studying  plans  for  the  three  hospitals  above 
mentioned. 

The  act  as  first  passed  provided  that  no  building  should  be  begun 
until  the  plans  for  all  hospitals  were  complete,  but  was  later 
amended  so  as  to  allow  the  Commission  to  start  the  building  of 
one  hospital  as  soon  as  it  had  submitted  plans  satisfactory  to  the 
Governor  and  Council,  which  reasonable  estimates  showed  could 
be  built  and  equipped  for  $100,000. 

The  difficulties  in  obtaining  suitable  sites  have  been  greater  than 
was  anticipated.  The  obvious  requirement  of  proximity  to  a 
railroad,  both  for  economy  of  administration  and  to  provide  easy 
access  to  patients  and  their  friends,  greatly  limits  the  choice. 
Economy  in  construction,  necessitated  by  the  small  appropriation, 
makes  it  imperative  to  select  land  that  is  level  and  well  cleared. 
A  high  and  dry  plateau,  where  water  can  be  obtained  cheaply  and 
where  sewage  disposal  can  be  safely  arranged,  is  not  easily  found. 
One  satisfactory  site  has  been  obtained  and  the  plans  for  the 
first  hospital  are  well  under  way. 

The  act  creating  this  Commission  is  designed  to  eventually  put 
under  its  charge  all  of  the  state  sanatoria  and  to  consolidate  all 
the  state  anti-tuberculosis  work  under  one  Board. 

While  the  Commission  has  been  searching  for  sites  and  planning 
these  hospitals  it  has  been  issuing  bulletins  at  short  intervals,  each 
bulletin  dealing  with  some  phase  of  the  tuberculosis  problem. 
These  bulletins  have  been  distributed  to  the  newspapers  through- 


CABOT.  9 

out  the  State  and  have  been  generally  published,  or  in  some  cases 
made  the  basis  of  an  article  or  "leader." 

The  Commission  has  also  constantly  urged  the  importance  of 
and  assisted  in  the  establishment  of  tuberculosis  dispensaries  or 
clinics,  day-camps,  anti-tuberculosis  associations  and  visiting 
nurses  in  various  parts  of  the  State. 

9.  Health  Districts  and  Inspectors.  — The  Legislature  of  1906-07, 
following  the  recommendations  of  Dr.  Walcott's  commission,  or- 
dered that  the  State  should  be  divided  into  districts,  and  that  a 
health  inspector,  appointed  by  the  Governor,  should  be  assigned 
to  each  district.  The  work  of  the  inspectors  is  considered  at 
length  in  a  subsequent  chapter. 

10.  The  Massachusetts  Federation  0}  IV omen's  Clubs.  —  Within 
the  past  year  the  Federation  of  Women's  Clubs  has  taken  an  active 
interest  in  the  matter  of  tuberculosis.  It  has  had  public  meetings 
in  various  places,  with  the  purpose  of  educating  the  community  in 
regard  to  tuberculosis,  and  in  certain  localities  has  taken  an  active 
part  in  the  effort  to  establish  anti-tuberculosis  associations,  day- 
camps  and  dispensaries. 

It  is  greatly  to  be  hoped  that  the  active  interest  among  the 
women  of  the  State  in  this  important  work  will  increase,  as  their 
assistance  in  educational  lines,  in  establishing  societies  and  clinics 
for  the  care  of  the  tuberculous  poor,  as  well  as  in  giving  individual 
assistance  to  those  needing  it,  can  become  a  very  powerful  factor 
in  the  work. 


10  TUBERCULOSIS    IN    MASSACHUSETTS. 


Chapter  II. 

THE  WORK  OF  THE  STATE  BOA.RD  OF  HEALTH. 
Charles  Harrington,  M.D. 

Massachusetts  was  the  first  of  the  States  to  estabhsh  a  State 
Board  of  Health,  and  this  was  done  in  1869.  Dr.  Henry  I.  Bow- 
ditch,  whose  investigation  of  the  influence  of  soil  moisture  on  the 
prevalence  of  consumption  in  New  England  had  given  him  an  in- 
ternational reputation  as  an  authority  on  pulmonary  consumption, 
was  appointed  chairman,  and  in  his  opening  address  at  the  first 
meeting  of  the  Board,  in  September,  1869,  he  laid  down  as  one  of 
the  fundamental  principles  of  a  board  of  health  that  it  is  "bound 
to  take  care  of  the  public  health,  to  investigate  the  causes  of  epi- 
demic and  other  diseases,  in  order  that  each  citizen  may  not  only 
have  as  long  a  life  as  nature  would  give  him,  but  likewise  as  healthy 
a  life  as  possible." 

The  Board's  first  secretary.  Dr.  George  Derby,  whose  statistical 
work  concerning  pulmonary  consumption  had  already  attracted 
much  attention,  said  in  his  first  report:  — 

If  there  is  any  one  disease  which  more  than  another  would  seem  to  favor  the 
views  of  the  advocates  of  the  predestined  and  the  inevitable,  it  is  that  terrible 
scourge,  far  more  to  be  dreaded  than  cholera,  consumption.  It  has  been  regarded 
as  a  special  mode  intended  by  Providence  to  reduce  a  redundant  population,  as 
feeble  trees  in  a  forest  are  crowded  out  of  existence  by  their  more  vigorous  neigh- 
bors. And  there  is  much  in  the  history  of  the  disease  which  makes  such  arguments 
plausible.  It  is  found  everywhere  in  civilized  communities,  in  the  South  as  well 
as  the  North,  seeming  to  be  generally  distributed.  Yet  the  kind  of  investigation 
of  its  natural  history  and  of  its  causes  which  we  are  able  to  make  in  these  latter 
days,  through  the  aid  of  vital  statistics,  and  by  the  comparison  of  great  numbers 
of  cases,  shows  that  this  is  far  from  being  true,  and  places  us  directly  upon  the 
path  leading  to  a  discovery  of  the  conditions  under  which  it  originates,  —  conditions 


HARRINGTON.  I  I 

which,  when  fully  recognized,  may  be  avoided.  That  its  causes  are  many  is  certain ; 
that  some  of  them  are  obscure,  and  even  quite  unknown  as  yet,  is  very  probable. 
But  others  are  fully  revealed,  and  are  influencing  practice  and  saving  life. 

Dr.  Derby  stated  that  an  examination  of  tiie  45,000  deaths 
from  consumption  that  had  occurred  during  ten  years  in 
Massachusetts  showed  that  its  distribution  in  the  State  was  very 
unequal,  in  some  of  the  communities  the  mortality  from  this  dis- 
ease being  two  and  even  three  times  that  of  others  of  equal  size  and 
equally  stationary  population.  He  emphasized  the  importance  of 
fresh  air,  and  gave  as  an  illustration  the  difference  in  the  fate  of 
two  individuals  with  similar  consumptive  tendency,  one  choosing 
to  make  shoes  in  an  ill-ventilated  shop  and  the  other  to  live  the 
life  of  a  lumberman  in  the  open  air,  the  latter  living  the  longer. 
"  But,"  he  said,  "our  grandfathers  did  not  know  even  that.  They 
protected  such  persons  from  fresh  air,  fearing  they  would  take  cold, 
coddled  them,  nourished  them  imperfectly,  and  gave  them  medi- 
cine." 

At  that  time  tuberculosis  was  already  declining  in  Massachusetts, 
through  the  influence  of  private  and  public  hygiene,  and  in  support 
of  his  statement  to  that  effect  Dr.  Derby  presented  a  table  showing 
that  whereas  in  1853  there  were  four  hundred  and  twenty-seven 
deaths  from  consumption  per  100,000  population,  the  curve  showed 
an  almost  constant  yearly  fall,  the  total  decline  being  about  20 
per  cent.  Comparing  the  first  and  the  last  groups  of  five  years, 
he  called  attention  to  the  annual  gain  of  six  hundred  and  eighty- 
eight  lives  saved,  and  ventured  the  opinion  that  this  saving 
was  due  to  the  advance  of  medical  science,  which  had  given 
to  physicians  a  better  knowledge  of  the  nature  of  the  disease,  a 
better  mode  of  treatment  and  a  greater  acquaintance  with  prophy- 
lactic measures.  "Fresh  air,  by  day  and  by  night,  strong  and 
nourishing  food,  dry  soil  on  which  to  live,  sunlight  and  warm  cloth- 
ing are  the  means  of  saving  many  lives  which  would  have  been 


12  TUBERCULOSIS    IN    MASSACHUSETTS. 

hopelessly  lost  in  the  preceding  generation.  ...  Let  in  the  sun- 
light, and  never  mind  the  carpets;  better  they  should  fade  than 
the  health  of  the  family." 

In  the  second  report  of  the  Board,  issued  in  January,  1871,  was 
presented  an  important  paper  on  the  ventilation  of  schoolhouses, 
emphasizing  the  necessity  of  a  continuous  supply  of  fresh  air,  and 
also  an  article  on  air  and  some  of  its  impurities,  in  which  the  im- 
portance of  dust  as  an  agent  in  impairing  the  general  health  was 
dwelt  upon. 

in  the  same  report  was  presented  a  reply  to  the  Legislature  of 
1870,  which  directed  the  Board  to  ascertain  the  whole  number  of 
minors  employed  in  the  textile  industries  of  the  State,  to  compare 
their  mortality  with  that  of  all  other  persons  of  the  same  age, 
during  the  same  periods  of  time,  and  to  report  upon  the  effect  of  the 
employment  upon  their  general  health  in  comparison  with  the 
effects  of  other  employments  upon  the  general  health  of  other  per- 
sons of  similar  ages.  At  this  time  it  appeared  that  about  40  per 
cent,  of  all  of  the  deaths  between  the  ages  of  fifteen  and  nineteen, 
inclusive,  in  Massachusetts,  were  due  to  pulmonary  consumption, 
and  the  Board  reported  that  the  mortality  among  minors  in  fac- 
tories, so  far  as  could  be  ascertained  from  the  returns  received,  was 
about  the  same  as  that  of  minors  in  the  general  population;  but 
attention  was  drawn  to  the  fact  that,  when  unfit  for  work  by  reason 
of  sickness,  and  particularly  in  the  first  stages  of  consumption,  a 
certain  proportion  of  the  operatives  withdrew  and  were  lost  sight 
of,  and  that,  such  being  the  case,  the  rate  of  mortality  among 
minors  in  textile  factories  was  really  higher  than  that  of  those  in 
the  general  population. 

The  fourth  annual  report  of  the  Board  presented  an  analysis  of 
a  correspondence  on  some  of  the  causes  or  antecedents  of  consump- 
tion with  two  hundred  and  ten  physicians  resident  in  Massachusetts 
and  elsewhere.    At  this  time  consumption  was  the  cause  of  about 


HARRINGTON.  I3 

one-fifth  of  the  annual  mortahty,  and  in  the  next  report  the  chair- 
man again  referred  to  it  as  the  most  important  disease  in  New 
England,  and  dwelt  upon  the  value  of  sanitary  houses,  proper  food 
and  clothing,  and  personal  hygiene,  including  exercise,  in  combat- 
ing its  ravages,  devoting  several  pages  to  the  consideration  of  each 
one  of  these  important  topics.  The  evils  of  damp  homes,  improper 
food  and  too  much  clothing  in  cold  weather,  and  the  value  of  long 
walks  in  winter,  even  for  young  girls,  and  of  keeping  the  skin  in 
good  condition  by  daily  bathing,  all  received  their  proper  share  of 
attention. 

The  chairman  deemed  recreation  as  of  the  greatest  importance 
at  all  stages  of  life,  but  particularly  in  childhood  and  youth.  The 
open-air  treatment  of  to-day  was  strongly  advocated  by  him  thirty- 
four  years  ago.  In  speaking  of  children  with  hereditary  tendencies, 
he  said:  "Such  a  child  should  be  compelled  to  find  some  recreation 
in  the  open  air."  He  would  make  it  a  rule  that  every  clerk  should 
walk  daily  two  or  three  miles,  and  for  a  few  weeks  annually  he 
should  leave  the  city  and  go  to  the  woods  or  the  seashore.  Camp- 
ing in  the  woods,  yachting  excursions,  pedestrian  tours,  —  all 
were  recommended  as  recreations  which  would  be  beneficial  for  all, 
and  especially  for  those  having  consumptive  tendencies.  "Noth- 
ing can  be  worse,"  he  said,  "for  all  youths,  especially  those  hered- 
itarily consumptive,  than  a  too  close  and  constant  attendance  at 
school,  college  or  counting-room." 

Recognizing  the  fact  above  stated,  that  one-fifth  of  the  deaths  in 
Massachusetts  were  due  to  consumption,  the  Board  in  its  earliest 
days  made  an  effort  to  ascertain  whether  this  high  rate  of  mor- 
tality could  not  be  lowered;  and  early  in  July,  1871,  a  circular  was 
issued  to  the  profession,  not  only  in  Massachusetts,  but  in  the  other 
New  England  States  and  elsewhere,  for  data  bearing  on  the  causes 
of  the  disease  and  the  factors  governing  its  spread. 

In  each  of  the  annual  reports  since  1884  have  been  presented 


I^  TUBERCULOSIS    IN    MASSACHUSETTS. 

charts  and  tables  showing  the  weekly  variation  in  the  mortality 
from  tuberculosis  during  the  year.  In  the  report  for  1891  were 
given  a  chart  showing  the  mortality  from  pulmonary  consumption 
from  1883  to  1 89 1,  inclusive,  and  for  1891  separately;  a  table 
showing  the  total  deaths  for  each  week  of  the  year  for  the  period  of 
nine  years;  and  a  map  which  showed  the  extent  to  which  each  city 
and  town  had  been  afflicted  with  the  disease  during  the  twenty 
years  ended  with  1890. 

In  the  report  for  1894  there  was  presented  a  chart  showing  the 
deaths  from  consumption  per  10,000  living,  from  185 1  to  1893. 
The  curve  is  of  great  interest,  and  shows  a  decline  from  forty-three 
in  1853  to  a  fraction  less  than  twenty-three  in  1893.  It  gave  also 
a  table  showing  the  annual  percentage  of  the  annual  mortality, 
which  percentage  had  fallen  from  more  than  22.90  to  1 1.25;  and 
the  deaths  by  sex  and  ages,  the  seasonal  distribution  and  the 
mortality  with  respect  to  density  of  population.  It  appeared  that 
the  mortality  in  dense,  medium  and  sparse  districts  varied  as 
1,810  and  727;  the  term  "dense"  applying  to  districts  having 
less  than  one  acre  per  inhabitant;  "medium,"  where  there  was 
more  than  one  acre  per  inhabitant  but  less  than  four;  and 
"sparse,"  where  there  were  more  than  four  acres  per  inhab- 
itant. 

In  1895  the  Board  issued  a  circular,  which  was  distributed  ex- 
tensively throughout  the  State,  to  furnish  information  to  the  pub- 
lic on:  — 

1 .  The  nature  of  pulmonary  consumption. 

2.  The  conditions  which  favor  its  spread. 

3.  The  best  methods  of  preventing  it. 

Under  the  second  were  discussed  defective  ventilation,  damp- 
ness of  soil,  overcrowding  of  dwellings,  factories  and  workshops, 
the  influence  of  dust,  of  insufficient  or  badly  selected  food  and  of 
intemperance. 


HARRINGTON.  1 5 

Under  the  third  were  presented  prophylactic  measures,  includ- 
ing prevention  of  overcrowding,  household  and  personal  cleanli- 
ness, proper  selection  of  occupation,  the  choice  of  a  well-balanced 
ration,  the  avoidance  of  overwork,  anxiety,  worry  and  exhaustion, 
the  disposal  of  sputum,  and  disinfection. 

A  short  time  after  this  circular  was  issued  there  appeared  a 
monograph  written  by  Dr.  J.  B.  Russell,  Senior  Medical  Officer  of 
Health,  of  Glasgow,  on  the  prevention  of  tuberculosis;  and, 
having  been  brought  to  the  attention  of  the  Board,  it  was  reprinted, 
with  the  consent  of  the  author,  and  5,000  copies  were  distributed 
throughout  the  State.  As  the  report  for  1896  says:  "No  publica- 
tion of  the  Board  has  been  received  and  read  with  greater  interest, 
and  it  is  hoped  that  much  benefit  will  be  derived  from  its  circula- 
tion." 

In  1896  was  begun  the  free  examination  of  sputum  or  other 
material  for  the  bacillus  of  tuberculosis,  suitable  packages  being 
furnished  by  the  Board  for  transmitting  the  material.  This  work 
has  grown  more  and  more  in  importance,  and  during  the  past  few 
years  the  number  of  specimens  sent  annually  to  the  Board's  lab- 
oratory has  exceeded  one  thousand.  These  specimens  come  from 
all  parts  of  the  State,  excepting  from  those  cities  and  towns  which 
maintain  diagnosis  laboratories  or  avail  themselves  of  the  services 
of  local  bacteriologists  and  pathologists.  At  the  present  time, 
however,  interest  in  tuberculosis  has  led  to  such  an  increase  in  the 
number  of  specimens  that  it  is  impossible  to  forecast  what  figure 
will  be  reached.  Possibly  the  recently  increased  resort  to  the 
laboratory  of  the  Board  may  be,  in  part,  attributable  to  the  fact 
that  in  1907  the  Legislature  passed  an  act  amending  certain  sec- 
tions of  chapter  75  of  the  Revised  Laws,  which  made  it  incumbent 
upon  the  Board  to  declare  what  diseases  should  be  regarded  as 
dangerous  to  the  public  health,  and  hence  notifiable  under  that 
chapter.     On  August   i,   1907,  the  Board  declared  eighteen  dis- 


l6  TUBERCULOSIS    IN    MASSACHUSETTS. 

eases  to  be  dangerous  and  notifiable,  and  tuberculosis  in  all  its 
forms  was  one  of  them. 

In  1905  the  Legislature  passed  a  resolve  authorizing  the  State 
Board  of  Health  "to  cause  a  public  exhibition  to  be  made  of  the 
various  means  and  methods  used  or  recommended  for  treating  and 
preventing  tuberculosis,  now  recognized  as  a  communicable  and 
preventable  disease;"  and  in  accordance  with  the  provisions  of 
the  resolve  an  exhibition  was  held  in  Horticultural  Hall,  Boston, 
from  December  28,  1905,  to  January  7,  1906,  inclusive.  An  aux- 
iliary committee  was  appointed  in  order  to  obtain  the  co-operation 
of  persons  interested  in  the  general  subject  who  would  assist  the 
Board  in  arousing  public  interest  and  advise  concerning  the  man- 
agement of  the  exhibition.  The  exhibition  was  advertised 
throughout  the  Commonwealth  by  means  of  circulars  and  circular 
letters  addressed  to  physicians,  philanthropists,  boards  of  health, 
managers  of  institutions,  secretaries  of  labor  unions,  superin- 
tendents of  schools,  officers  of  all  of  the  colleges  and  institutions 
of  higher  learning,  manufacturers,  owners  of  large  mercantile 
establishments  and  trained  nurses.  Additional  publicity  was 
secured  through  posters  and  cards  printed  in  Hebrew  and  Italian. 

The  material  shown  was  contributed  by  various  health  organi- 
zations, institutions  and  tuberculosis  societies  and  associations, 
and  was  exceedingly  valuable  and  interesting.  It  drew  a  total 
attendance  of  25,953  persons,  or  an  average  daily  of  2,359.  Dur- 
ing the  exhibition,  a  number  of  special  meetings  were  held,  which 
were  addressed  by  men  qualified  to  represent  all  classes  concerned 
in  this  movement,  —  physicians,  employers,  workingmen,  philan- 
thropists, health  authorities,  teachers,  managers  of  public  and  pri- 
vate institutions,  and  others.  These  meetings  were  attended  by 
a  total  of  5,275  persons.  There  was  also  given  a  series  of  seven 
lantern-slide  demonstrations,  which  drew  a  total  of  2,625  persons. 

The  exhibition  fulfilled  the  purpose  for  which  it  was  held  in  a 


HARRINGTON. 


'7 


very  satisfactory  manner,  and  led  to  the  holding  of  many  similar 
though  smaller  exhibitions  in  various  parts  of  the  State. 

In  its  report  to  the  Legislature  of  1906,  on  the  sanitary  condi- 
tion of  factories,  the  Board  laid  especial  emphasis  on  the  influence 
of  dust  and  lack  of  ventilation  in  causing  the  spread  of  tubercu- 
losis, and  made  a  number  of  recommendations  concerning  the 
sanitation  of  factories  and  the  protection  of  the  health  of  em- 
ployees. These,  with  other  influences,  led  to  the  division  of  the 
State  into  fifteen  health  districts  and  the  appointment  in  each  of  a 
state  inspector  of  health,  one  of  whose  principal  duties  is  to  gather 
all  information  possible  concerning  the  prevalence  of  tuberculosis 
and  other  diseases  dangerous  to  the  public  health  within  his  dis- 
trict, and  to  disseminate  knowledge  as  to  the  best  methods  of  pre- 
venting their  spread.  Under  the  provisions  of  this  act  all  minors 
employed  in  factories  are  subject  to  examination  by  the  state  in- 
spectors of  health,  who  are  required  to  call  any  condition  of  ill 
health  or  physical  unfitness  detected  to  the  attention  of  the 
minor's  parents  or  employers  and  also  to  the  State  Board  of  Health. 
The  work  of  this  department  of  the  Board  is  considered  in  another 
chapter. 


TUBERCULOSIS    IN    MASSACHUSETTS. 


Chapter  III. 

THE  WORK  OF  THE  STATE  INSPECTORS  OF  HEALTH. 
William  C.  Hanson,  M.D. 

On  June  19,  1907,  Governor  Guild  approved  an  act  which  pro- 
vided for  the  establishment  of  fifteen  health  districts  and  the  ap- 
pointment of  a  physician  as  state  inspector  of  health  in  each  dis- 
trict. This  act  further  provided  that  the  state  inspectors  of  health 
should  be  under  the  general  supervision  of  the  State  Board  of 
Health,  and  that  they  should  perform  such  duties  other  than 
those  specifically  imposed  upon  them  as  the  said  Board  from  time 
to  time  should  determine. 

Broadly  stated,  the  duties  of  the  state  inspectors  of  health  fall 
into  four  main  groups:  each  inspector  is  required  to  inform  him- 
self respecting,  first,  all  influences  which  may  be  dangerous  to  the 
public  health;  second,  the  prevalence  of  tuberculosis  and  other 
diseases  dangerous  to  the  public  health  within  his  district;  third, 
the  health  of  all  minors  employed  in  factories  within  his  district; 
and  fourth,  the  sanitation  of  factories,  slaughterhouses,  public 
buildings  and  tenements  in  which  clothing  is  manufactured.  In 
performing  the  duties  under  the  first  and  second,  the  inspectors  act 
as  intermediaries  between  the  State  Board  of  Health  and  the  local 
health  authorities.  For  example,  in  the  matter  of  preventing, 
destroying  or  mitigating  nuisances,  which  endanger  human  life  or 
health,  the  local  boards  of  health  have  almost  absolute  authority; 
but  the  function  of  the  state  inspectors  of  health  is  to  investigate 
such  nuisances  for  the  purpose  of  notifying  local  health  authorities 
of  their  powers  and  duties  relative  thereto,  and  of  recommending 
such  measures  as  may  be  deemed  expedient  for  the  promotion  of 


HANSON.  19 

the  public  health.  At  the  same  time  copies  of  all  written  sug- 
gestions made  by  the  state  inspectors  to  the  local  health 
authorities  are  sent  to  the  State  Board  of  Health.  In  the  matter 
of  investigating  contagious  diseases,  and  all  diseases  dangerous 
to  the  public  health,  the  inspectors  have  full  power,  but  may 
only  take  steps  toward  the  eradication  of  any  such  diseases  after 
consultation  with  the  State  Board  of  Health  and  the  local  board. 
In  performing  the  duties  under  the  third  and  fourth,  relating  to  the 
health  of  minors  and  the  sanitation  of  buildings,  the  inspectors  act 
independently  of  local  health  authorities  and  under  the  direction 
of  the  State  Board  of  Health. 

It  must  be  clear  that  the  duties  of  these  inspectors  are  manifold. 
There  is,  however,  but  one  object  in  view,  namely,  to  guard  the 
public  health.  In  this  work  their  position  is  unique,  for  with  their 
medical  knowledge  —  which  is  indispensable  to  the  proper  en- 
forcement of  the  statutes  —  they  may  appeal  to  the  medical  pro- 
fession on  the  one  hand  and  to  the  laity  on  the  other,  teaching  all 
that  the  promotion  of  public  health  is  a  matter  which  concerns  not 
only  the  medical  profession  but  every  profession  and  every  indi- 
vidual. 

The  one  health  problem  which  more  than  all  others,  at  the  pres- 
ent time,  demands  the  services  of  all  professions  and  of  every  per- 
son in  his  respective  sphere,  is  that  of  diminishing  the  prevalence 
of  tuberculosis.  Now  that  the  matter  has  been  brought  earnestly 
to  public  attention,  it  should  be  kept  before  the  public,  with  ever- 
increasing  emphasis  upon  the  importance  of  sanitary  education. 
Reform  cannot  be  complete  as  long  as  sanitary  science  is  considered 
inferior  in  interest  and  importance  to  any  other  branch  of  educa- 
tion. 

In  this  connection  it  is  interesting  to  observe  that  the  beginning 
of  the  state  work  marks  the  lapse  of  upwards  of  half  a  century 
since  Lemuel  Shattuck  brought  to  the  attention  of  the  Massachu- 


20  TUBERCULOSIS    IN    MASSACHUSETTS. 

setts  Legislature  the  necessity  for  "particular  observation  and  in- 
vestigation of  the  causes  of  consumption  and  the  circumstances 
under  which  it  occurs,"  on  the  ground  that  "if  consumption  is  ever 
to  be  eradicated  or  ameliorated  it  can  only  be  done  by  preventive 
means  and  not  by  cure."     The  report  continues:  — 

We  cannot  too  strongly  impress  upon  local  boards  of  health,  upon  the  members 
of  the  medical  profession,  and  upon  all  others  interested,  the  importance  of  making 
a  united  and  energetic  effort  to  obtain  such  observations  concerning  every  case 
which  occurs  in  every  part  of  the  Commonwealth.  Nearly  three  thousand  cases 
in  this  State  annually  terminate  in  death;  and  if  they  were  properly  observed, 
for  a  series  of  five,  ten  or  more  years,  it  is  impossible  to  anticipate  the  good  results 
which  might  follow.  Possibly,  —  and  even  probably,  —  discoveries  might  be 
made  which  would  reduce  the  annual  number  of  cases,  certainly  by  hundreds, 
and  perhaps  by  thousands.  We  shall  hereafter  suggest  a  form  of  a  register  of  cases 
adapted  to  this  object;  and  the  great  importance  of  the  disease,  and  the  confident 
hope  that  some  discovery  can  be  made  which  will  materially  abate  its  melancholy 
ravages,  should  arouse  us  all  to  action.' 

Notwithstanding  this  valuable  recommendation  to  the  Massa- 
chusetts Legislature  of  1850,  it  remained  for  the  Legislature  of 
1907  to  pass  acts  which  made  it  possible  for  the  State  Board  of 
Health  to  require  the  registration  of  all  cases  of  tuberculosis,  and, 
through  the  state  inspectors  of  health,  to  gather  all  information 
possible  concerning  the  prevalence  of  this  disease. 

The  authority  given  to  the  state  inspectors  for  taking  steps 
toward  the  prevention  of  tuberculosis  is  limited  only  by  the  many 
specific  statute  requirements  relative  to  the  sanitation  of  buildings, 
and  by  the  express  provision  that  the  inspectors  shall  inform 
themselves  concerning  the  health  of  all  minors  employed  in  fac- 
tories. These  two  spheres  of  specific  duties  are  themselves  im- 
mense, and  it  is  easy  to  forecast  a  great  advancement  in  sanitary 
science  along  the  lines  which  they  include;  namely,  the  hygiene  of 
occupation  and  the  sanitation  of  public  buildings,  and  the  sanita- 
tion of  tenement  workrooms  and  workshops  wherein  clothing  is 

'  Report  of  the  Sanitary  Commission  of  Massachusetts,  1850,  page  181. 


HANSON.  21 

manufactured.  In  all  these  phases  of  sanitary  work  the  investi- 
gation of  the  prevalence  of  tuberculosis  plays  an  exceedingly  im- 
portant part.  The  inspector  in  a  factory  community  bears  in 
mind  the  hygiene  of  the  town  or  city,  especially  in  the  workmen's 
quarters,  and  is  ready  to  make  an  investigation  of  the  existence  of 
tuberculosis  or  of  any  other  disease  dangerous  to  the  public 
health.  Within  the  factory,  the  inspector,  knowing  that  tuber- 
culosis of  the  lungs  is  a  common  consequence  of  overcrowding  and 
exposure  to  vitiated  air  and  dust,  —  including  the  various  kinds  of 
trade  dust  and  other  impurities  injurious  to  health  which  are 
generated  in  the  course  of  the  manufacturing  process  carried  on 
therein,  —  pays  especial  attention  to  ventilation.  If,  in  his 
opinion,  mechanical  appliances  are  necessary  for  the  protection  of 
employees  against  dust,  he  may  require  that  such  appliances  shall 
be  provided,  maintained  and  used.  In  order  to  properly  inform 
himself  concerning  the  health  of  minors  employed  in  a  given  fac- 
tory, each  inspector  is  required  to  ascertain  of  every  minor  if  the 
family  history  discloses  illness  or  death  due  to  tuberculosis,  or  any 
disease  to  which  the  minor  himself  seems  liable.  Whenever  the 
family  history  discloses  illness  or  death  of  any  member  due  to 
tuberculosis,  the  inspector  makes  a  physical  examination  of  the 
minor;  and  in  every  instance,  whether  or  not  a  physical  exam- 
ination is  made,  the  inspector  submits  a  concise  report  on  the 
immediate  sanitary  conditions  under  which  the  minor  works, 
apart  from  the  general  report  which  covers  details  relative  to  the 
lighting,  ventilation  and  cleanliness  of  the  entire  factory. 

The  tenement  workroom  problem  is  limited  to  those  tenements 
and  dwellings  in  which  clothing  is  manufactured  by  members  of 
the  family  working  there.  Persons  doing  such  work  must  be 
licensed  and  the  rooms  in  which  the  work  is  done  must  be  kept 
clean.  In  case  the  inspector  finds  evidence  of  tuberculosis  or 
other  disease  dangerous  to  the  public  health,  as  a  contagious  skin 


22  TUBERCULOSIS    IN    MASSACHUSETTS. 

disease,  in  one  of  these  dwellings,  he  may  or  may  not  revoke  the 
license,  as  occasion  requires;  but  whenever  he  does  revoke  a  li- 
cense for  such  reason  he  is  obliged  to  report  his  findings  at  once  to 
the  State  Board  of  Health,  which  notifies  the  local  board  of  health 
(unless  notification  has  already  been  made)  to  examine  said  dwell- 
ing for  the  purpose  of  issuing  such  orders  as  the  public  safety  may 
demand.  Since  the  tuberculosis  problem  is  closely  connected 
with  that  of  the  tenement  workroom  and  the  workshops  wherein 
clothing  is  manufactured,  and  since  the  majority  of  these  work- 
rooms are  situated  in  Suffolk  County,  the  state  inspector  of  health 
of  this  district.  Dr.  Linenthal,  has  made  a  careful  study  of  the 
types  of  such  dwellings  and  the  sanitary  conditions  in  them.  For 
this  reason,  and  because  the  types  of  dwellings  and  workshops 
described  by  Dr.  Linenthal  include  those  situated  in  other  parts  of 
the  State  as  well,  and  because  of  the  practical  importance  of  the 
investigation,  he  has  been  asked  to  present  the  facts  relative  thereto 
in  a  separate  chapter. 

The  work  pertaining  to  factory  hygiene  is  of  such  magnitude  and 
presents  so  many  problems,  some  of  which  will  require  much  time 
and  patience  for  a  proper  solution,  that  it  is  impossible  at  present 
to  give  information  which  would  add  appreciably  to  that  already 
contained  in  the  recent  "  Report  of  the  State  Board  of  Health  upon 
the  Sanitation  of  Factories  and  Workshops."  In  the  meantime, 
there  are  many  things  which  the  public  can  do  and  ought  to  do  in 
order  to  make  the  work  of  the  state  inspectors  of  health  more 
effective. 

if,  for  example,  any  citizen  knows  of  a  person  suffering  with 
tuberculosis  who  is  not  receiving  proper  care,  or  who,  through 
carelessness  and  neglect,  is  endangering  others,  it  is  clearly  the 
duty  of  that  citizen  to  notify  the  state  inspector  for  his  district. 
In  the  same  way  private  individuals,  physicians,  social  service 
workers  and  organizations  of  various  kinds  may  be  of  great  as- 


HANSON.  23 

sistance  to  the  inspectors  by  calling  to  their  attention  any  unsan- 
itary conditions,  diseases  or  influences  dangerous  to  the  public 
health,  or  threatening  to  affect  the  same.  Since  the  law  requiring 
that  every  public  building  and  every  schoolhouse  shall  be  ade- 
quately ventilated  is  to  be  enforced  by  these  health  officials,  medical 
inspectors  of  schools  and  teachers  should  notify  them  of  any  vio- 
lation of  this  law.  Notice  of  any  ill-ventilated  or  overcrowded 
schoolhouse  should  be  brought  to  the  attention  of  the  state  in- 
spector in  whose  district  the  schoolhouse  is  located.  It  is  of  the 
greatest  importance  that  factories  and  workshops  should  likewise 
be  well  ventilated  and  not  overcrowded.  Persons  who  work  day 
after  day  in  crowded  rooms  which  are  not  properly  ventilated 
must  after  a  time  suffer  a  loss  of  resistance  to  disease,  and,  in 
consequence,  become  more  susceptible  to  tuberculosis.  This  is 
especially  true  of  a  workshop  where  many  people  work  side  by 
side,  some  of  whom  may  be  suffering  with  tuberculosis  of  the  lungs. 
One  of  the  most  "important  duties  of  an  employer,  therefore, 
is  to  provide  fresh  air  for  his  employees. 

Another  duty  of  the  public,  equally  important  with  those  men- 
tioned, is  to  remember  that  a  tuberculous  person  whose  personal 
habits  are  clean,  and  who  properly  disposes  of  his  sputum,  is  not  a 
source  of  danger  to  those  about  him.  Failure  to  appreciate  this 
fact  is  already  causing  many  hardships  which  are  both  unnecessary 
and  unjust.  It  is  not  at  all  uncommon  to-day  to  hear  of  instances 
where  the  very  means  of  obtaining  one's  livelihood  have  been  taken 
away  because  the  person  was  unfortunate  enough  to  be  afflicted 
with  tuberculosis.  To  take  away  from  such  a  person  the  means  of 
obtaining  his  livelihood  is  to  take  it  from  the  very  person  who 
needs  it  most.  On  the  other  hand,  to  meet  the  problem  fairly, 
the  healthy  employees,  both  minors  and  adults,  should  be  properly 
protected  from  all  ignorant  or  careless  consumptives.  At  the 
present  time  investigations  are  being  made  concerning  the  health 


24  TUBERCULOSIS    IN    MASSACHUSETTS. 

and  the  influence  of  occupation  upon  the  health  of  children  and 
young  persons,  but  there  is  no  law  by  which  adults  working  in 
factories  may  be  examined,  and  such  steps  taken  as  may  be 
deemed  advisable  or  necessary  for  guarding  the  public  health. 

The  duties  of  the  state  inspectors  of  health  relating  to  tuber- 
culosis may  be  stated  briefly  as  follows:  first,  to  gather  all  infor- 
mation possible  concerning  its  prevalence;  second,  to  disseminate 
knowledge  as  to  the  best  methods  of  preventing  its  spread;  third, 
to  report  to  the  State  Board  of  Health  any  minor  employed  in  a 
factory  who  is  known  to  have  any  form  of  the  disease;  fourth,  to 
report  to  the  State  Board  of  Health  and  to  the  proper  local  health 
authority  every  case  discovered  in  a  tenement  workshop;  fifth,  to 
notify  local  boards  of  health  of  any  person  found  to  be  endangering 
the  public  health;  and  sixth,  to  see  that  the  notification  laws, 
which  require  householders  and  physicians  to  report  any  known 
case  to  local  health  authorities,  are  enforced. 

Following  are  the  names  and  addresses  of  the  state  inspectors  of 
health  who  were  appointed  by  the  Governor  on  the  tenth  day  of 
July,  1907:  — 

District  No.  i.  —  Dr.  Charles  E.  Morse,  Wareham. 

District  No.  2.  —  Dr.  Adam  S.  MacKnight,  355  North  Main 
Street,  Fall  River. 

District  No.  3.  —  Dr.  Wallace  C.  Keith,  237  North  Main  Street, 
Brockton. 

District  No.  4.  —  Dr.  Elliott  Washburn,  50  Broadway,  Taunton. 

District  No.  5.  —  Dr.  Harry  Linenthal,  327  Blue  Hill  Avenue, 
Roxbury. 

District  No.  6.  —  Dr.  Albert  P.  Norris,  728  Massachusetts  Ave- 
nue, Cambridge. 

District  No.  7.  —  Dr.  J.  William  Voss,  i  Dane  Street,  Beverly. 

District  No.  8.  —  Dr.  William  Hall  Coon,  70  Newbury  Street, 
Lawrence. 


HANSON.  25 

District  No.  9.  —  Dr.  Charles  E.  Simpson,  Lowell  Hospital, 
Lowell. 

District  No.  10.  —  Dr.  William  W.  Walcott,  32  West  Central 
Street,  Natick. 

District  No.  11.  —  Dr.  Melvin  G.  Overlock,  91  Chandler  Street, 
Worcester. 

District  No.  12.  —  Dr.  Lewis  Fish,  7  Highland  Avenue,  Fitch- 
burg. 

District  No.  13.  —  Dr.  Harvey  T.  Shores,  177  Elm  Street, 
Northampton. 

District  No.  14.  —  Dr.  Richard  S.  Benner/  10  Chestnut  Street, 
Springfield. 

District  No.  15.  —  Dr.  Lyman  A.  Jones,  170  Main  Street, 
North  Adams. 

Under  the  rules,  consideration  was  postponed  until  July  17, 
when  the  appointments  were  severally  confirmed  by  the 
Council. 

The  division  of  health  districts  was  made  on  July  9,  1907.  The 
districts  are  as  follows:  — 

Health  District  No.  i.  —  Includes  the  counties  of  Barnstable, 
Dukes  and  Nantucket,  and  the  town  of  Wareham. 

Health  District  No.  2.  —  Includes  the  cities  of  Fall  River  and 
New  Bedford,  and  the  towns  of  Acushnet,  Berkeley,  Dartmouth, 
Dighton,  Fairhaven,  Freetown,  Marion,  Mattapoisett,  Rehoboth, 
Rochester,  Seekonk,  Somerset,  Swansea  and  Westport. 

Health  District  No.  3.  —  Includes  Plymouth  County,  exclusive 
of  the  towns  of  Marion,  Mattapoisett,  Rochester  and  Wareham, 
and,  in  addition,  the  towns  of  Cohasset  and  Weymouth. 

Health  District  No.  4.  —  Includes  the  cities  of  Quincy  and  Taun- 
ton, and  the  towns  of  Attleborough,  Avon,  Bellingham,  Blackstone, 
Braintree,  Canton,  Dedham,  Easton,  Foxborough,  Franklin,  Hol- 

1  Resigned  in  October,  1907.     Succeeded  by  Dr.  Herbert  C.  Emerson,  177  State  Street,  Springfield. 


26  TUBERCULOSIS    IN    MASSACHUSETTS. 

brook,  Hyde  Park,  Mansfield,  Milton,  Norfolk,  Norton,  North 
Attleborough,  Norwood,  Plainville,  Randolph,  Raynham,  Sharon, 
Stoughton,  Walpole,  Westwood  and  Wrentham. 

Health  District  No.  5.  —  Includes  Suffolk  County. 

Health  District  No.  6.  —  Includes  the  cities  of  Cambridge,  Ev- 
erett, Maiden,  Medford,  Melrose  and  Somerville,  and  the  towns  of 
North  Reading,  Reading,  Stoneham  and  Wakefield. 

Health  District  No.  7.  —  Includes  the  cities  of  Beverly,  Glouces- 
ter, Lynn  and  Salem,  and  the  towns  of  Dan  vers,  Essex,  Ipswich, 
Hamilton,  Lynnfield,  Manchester,  Marblehead,  Middleton,  Na- 
hant,  Peabody,  Rockport,  Saugus,  Swampscott,  Topsfield  and 
Wenham. 

Health  District  No.  8.  —  Includes  the  cities  of  Haverhill,  Law- 
rence and  Newburyport,  and  the  towns  of  Amesbury,  Andover, 
Boxford,  Georgetown,  Groveland,  Merrimac,  Methuen,  Newbury, 
North  Andover,  Rowley,  Salisbury  and  West  Newbury. 

Health  District  No.  9.  —  Includes  the  cities  of  Lowell  and  Wo- 
burn,  and  the  towns  of  Acton,  Arlington,  Ayer,  Bedford,  Billerica, 
Boxborough,  Burlington,  Carlisle,  Chelmsford,  Concord,  Dracut, 
Dunstable,  Groton,  Harvard,  Lexington,  Lincoln,  Littleton, 
Maynard,  Pepperell,  Shirley,  Stow,  Tewksbury,  Townsend, 
Tyngsborough,  Westford,  Wilmington  and  Winchester. 

Health  District  No.  10.  —  Includes  the  cities  of  Marlborough, 
Newton  and  Waltham,  and  the  towns  of  Ashland,  Belmont, 
Brookline,  Dover,  Framingham,  Grafton,  Holliston,  Hopedale, 
Hopkinton,  Hudson,  Medfield,  Medway,  Mendon,  Milford,  Millis, 
Natick,  Needham,  Northborough,  Sherborn,  Shrewsbury,  South- 
borough,  Sudbury,  Upton,  Watertown,  Wayland,  Wellesley,  West- 
borough  and  Weston. 

Health  District  No.  11.  —  Includes  the  city  of  Worcester,  and 
the  towns  of  Auburn,  Brookfield,  Charlton,  Douglas,  Dudley, 
Leicester,    Millbury,    Northbridge,    North     Brookfield,    Oxford, 


HANSON.  27 

Southbridge,  Spencer,  Sturbridge,  Sutton,  Uxbridge,  Warren, 
Webster  and  West  Brookfield. 

Health  District  No.  12. —  Includes  the  city  of  Fitchburg,  and 
the  towns  of  Ashburnham,  Ashby,  Athol,  Barre,  Bedin,  Bolton, 
Boylston,  Clinton,  Dana,  Gardner,  Hardwick,  Holden,  Hub- 
bardston,  Lancaster,  Leominster,  Lunenburg,  New  Braintree, 
Oakham,  Paxton,  Petersham,  Phillipston,  Princeton,  Royalston, 
Rutland,  Sterling,  Templeton,  Westminster,  Winchendon  and 
West   Boylston. 

Health  District  No.  13.  —  Includes  all  of  Franklin  County,  and  all 
of  Hampshire  County  excepting  the  towns  of  Huntington,  Middle- 
field  and  Worthington. 

Health  District  No.  14.  —  Includes  all  of  Hampden  County, 
and,  in  addition,  the  towns  of  Huntington,  Middlefield  and 
Worthington. 

Health  District  No.  15.  —  Includes  all  of  Berkshire  County. 


28  TUBERCULOSIS    IN    MASSACHUSETTS. 


Chapter  IV. 

SANITATION  OF  CLOTHING  FACTORIES  AND  TENEMENT- 
HOUSE  WORKROOMS. 

H.  Linenthal,  M.D. 

A  great  deal  has  been  said  and  written  about  the  crowded, 
badly  ventilated,  poorly  lighted  tenement  houses  of  our  large 
cities,  and  we  are  aware  of  the  fact  that  these  houses  furnish  con- 
ditions favorable  to  the  spread  of  tuberculosis.  Not  quite  so 
much  is  generally  known,  however,  regarding  the  conditions  of  the 
factories  or  "tailor  shops"  where  men's  clothing  is  made.  A 
brief  statement  of  the  conditions  found  in  these  shops  may,  there- 
fore, be  of  interest  to  those  engaged  in  the  crusade  against  tuber- 
culosis. It  will  also  throw  some  light  on  the  causes  of  the  increase 
of  tuberculosis  among  the  operatives  of  a  trade  which,  in  itself, 
cannot  be  regarded  as  the  direct  cause  of  the  disease. 

Although  the  majority  of  the  tailors  in  Boston  are  Jews,  who  are 
supposed  to  possess  a  relative  immunity  to  tuberculosis,  yet  — 
and  this  is  the  general  impression  of  the  physicians  practicing 
among  them  —  their  number  afflicted  with  tuberculosis  is  on  the 
increase.  Most  of  the  tailor  shops  are  located  in  the  North  and 
South  Ends  of  the  city.  In  some  instances  there  are  as  many  as 
eight  or  ten  in  the  same  building,  while  the  number  of  workmen 
employed  in  each  shop  varies  from  ten  to  sixty.  The  buildings  are 
for  the  most  part  in  a  neglected  condition,  and  proper  sanitation 
cannot  possibly  be  maintained.  For  the  cleanliness  of  the  stairs, 
hallways  and  toilets,  which  are  used  by  the  occupants  in  common, 
no  one  seems  to  be  responsible;  they  are  consequently  very  dirty. 
The  closets  in  many  cases  are  foul  and  reek  with  filth.  The  land- 
lord, through  a  janitor,  is  supposed  to  look  out  for  the  cleanliness 


LINENTHAL.  29 

of  the  public  parts  of  the  building;  but  the  activity  of  the  janitor, 
if  he  exists,  is  not  manifest.  The  interiors  of  the  shops  are  very 
unclean;  the  dirty  walls  and  ceilings  appear  not  to  have  received 
a  coat  of  whitewash  for  years;  and  the  windows  are  often  so  dusty  " 
as  to  be  almost  opaque.  In  most  of  the  shops  the  unsanitary  con- 
ditions of  the  buildings  are  made  worse  by  the  slovenly,  uncleanly 
habits  of  the  contractors  as  well  as  of  their  employees.  Dust, 
rags  and  other  refuse  are  allowed  to  accumulate  in  the  corners  of 
the  shops  and  under  the  tables.  The  habit  of  spitting  on  the  floor 
is  evident  in  almost  every  shop.  To  appreciate  fully  the  signifi- 
cance of  this  disgusting  and  dangerous  habit  one  need  but  visit 
the  shop  in  operation.  Various  parts  of  the  garment  are  made  by 
different  operators.  When  the  operator  has  finished  the  part  al- 
loted  to  him  he  throws  it  on  the  floor.  The  garment  is  then  picked 
up  by  the  foreman,  who  passes  it  to  the  next  operator.  The  dried 
as  well  as  the  moist  sputum  may  thus  be  freely  circulated  among 
the  operators  by  the  contaminated  clothing.  When  the  shop  is 
swept,  as  happens  on  rare  occasions,  the  sweeping  is  usually  dry 
and  helps  to  stir  the  dust.  Is  it  surprising  that  people  continually 
exposed  to  such  conditions  become  tuberculous? 

The  attitude  of  most  of  the  contractors  is  that  filth  is  a  natural 
and  necessary  condition,  and  that  it  is  unreasonable  to  expect  a 
proper  standard  of  cleanliness.  "What  do  you  expect?  This  is 
not  a  parlor  or  a  ballroom."  "Of  course  they  spit  on  the  fioor; 
where  do  you  expect  them  to  spit,  in  their  pockets?"  "Do  you 
want  us  to  make  parlors  of  our  workshops?"  were  remarks  often 
heard  when  the  unsanitary  conditions  were  pointed  out  to  the 
employers.  In  several  instances  I  was  told  that  the  employees  do 
not  spit  on  the  floor,  but  on  heaps  of  rags  in  the  corners.  Inves- 
tigation showed  that  these  rags  are  later  sorted  by  hand  in  the 
rag  shops. 

What  is  to  be  said  of  the  possibility  that  clothing  thus  exposed 


30 


TUBERCULOSIS    IN    MASSACHUSETTS. 


to  infection  may  be  a  factor  in  the  spread  of  tuberculosis?  There 
are  on  record  well-authenticated  cases  where  diphtheria  was  con- 
tracted by  the  wearers  of  garments  manufactured  in  tenement 
houses  where  diphtheria  existed.  In  a  disease  so  widespread  as 
tuberculosis,  where  the  foci  of  infection  are  so  numerous,  it  is  im- 
possible to  trace  definitely  any  one  case;  but  it  is  quite  probable 
that  tubercle  bacilli  are  carried  from  the  shops  by  the  infected 
garments. 

In  the  opinion  of  the  manufacturers,  the  conditions  in  the  manu- 
facture of  clothing  have  vastly  improved  in  the  last  ten  years. 
"At  one  time,"  one  manufacturer  told  me  the  other  day,  "before 
the  garments  were  put  in  the  store,  it  was  necessary  to  air  them 
on  the  roof  to  rid  them  of  vermin."  This  is  no  longer  necessary, 
as  he  has  "not  seen  a  bedbug  in  the  clothing  for  a  number  of 
years." 

The  reader  will  undoubtedly  feel  that  his  clothing,  at  least,  is 
not  made  under  such  unsanitary  conditions.  His  clothing,  or- 
dered perhaps  from  a  fashionable  tailor  in  the  city,  is  custom- 
made.  I  regret  to  disillusionize  him.  The  fashionable  tailor 
does  not  make  the  clothing  on  his  own  premises;  the  cut  material 
is  sent  out  to  the  shops  of  custom  tailors,  most  of  which  are  very 
small,  extremely  filthy  and  far  more  unsanitary  than  the  shops 
where  ready-made  clothing  is  manufactured.  From  one  of  these 
shops,  consisting  of  a  room  not  larger  than  five  yards  square, 
which  I  had  ordered  to  be  cleaned,  four  barrels  of  dirt,  rags  and 
other  refuse  were  removed.  So  striking  was  the  change  produced 
in  the  shop  that  the  owner  sent  me  a  letter  of  thanks  for  having 
ordered  him  to  clean  his  premises.  The  expensive  custom-made 
suit  is  thus  manufactured  under  worse  sanitary  conditions  than 
the  cheaper  ready-made  suit. 

Another  important  factor  of  the  clothing  industry  from  the 
standpoint  of  public  health  is  the  tenement  workroom.     In  the 


LINENTHAL.  3I 

making  of  trousers  there  is  considerable  sewing  to  be  done  by  hand, 
and  the  contractors,  the  people  who  operate  the  tailor  shops,  find 
it  cheaper  to  have  this  work  done  by  outside  finishers,  who  work 
for  very  little  and  thus  set  the  rate  of  wage  for  those  who  do  the 
same  work  in  the  shops.  The  work  of  finishing  pants  is  carried  on 
almost  entirely  by  Italian  women  in  the  most  congested  district 
of  Boston.  In  connection  with  these  workrooms  the  question  of 
public  health  becomes  quite  prominent,  and  the  maintenance  of 
proper  sanitary  conditions  requires  frequent  inspection.  Over- 
crowding, dark,  poorly  ventilated  and  dirty  halls,  bedrooms  with 
windows  opening  into  narrow,  unclean  alleys  or  airshafts,  and 
rooms  with  no  windows  at  all,  are  some  of  the  conditions  one  meets. 
When  confronted  with  these  conditions  one  cannot  help  feeling 
how  inadequate  are  our  efforts  to  prevent  the  spread  of  tubercu- 
losis, and  how  far  off  we  are  from  striking  at  the  root  of  the 
evil. 

Among  the  tenement  workrooms  inspected  I  came  across  a  two- 
room  flat  on  the  top  floor  of  a  building  situated  in  a  narrow,  dirty 
street  in  the  North  End.  In  these  rooms  there  lived  a  young  man 
of  twenty-five  with  his  mother  and  grandmother.  The  two 
women  finished  pants  at  home,  —  their  only  means  of  subsistence. 
The  young  man  was  consumptive  and  unable  to  work.  A  small, 
low-studded  room,  used  as  kitchen  and  workroom,  served  at  night 
as  a  bedroom  for  the  consumptive.  When  I  visited  the  place  a 
kerosene  stove  was  burning  and  the  family  dinner  cooking.  The 
windows  were  tightly  closed,  and  the  air  in  the  room  was  suffo- 
cating. The  young  consumptive  stayed  at  home,  as  he  was  "in- 
disposed" to  go  out.  He  subsequently  went  to  the  Rutland 
Sanatorium  for  several  months,  and  the  disease  was  apparently 
arrested.  But  what  chance  has  he  of  remaining  well  when  he  has 
to  live  now  in  the  same  two-room  flat,  under  the  same  unsanitary 
conditions?     In  all  probability  a  relapse  will  occur,  and  the  time. 


32 


TUBERCULOSIS    IN    MASSACHUSETTS. 


money  and  energy  spent  to  arrest  the  disease  must  be  duplicated, 
and  with  smaller  chances  of  success. 

The  children  living  in  the  tenement  workrooms  are  pale  and 
many  of  them  show  evidences  of  impaired  nutrition.  The  infants, 
however,  look  surprisingly  plump  and  well  nourished.  So  long  as 
the  child  receives  its  nourishment  from  its  mother's  milk  it  thrives. 
Life  to  these  children  is  quite  a  serious  affair;  they  know  not  of 
childhood,  since  at  a  very  early  age  household  responsibilities  are 
thrown  upon  them.  On  several  occasions  1  have  seen  girls  of  ten 
or  eleven  years  of  age  doing  the  family  washing,  while  the  mother 
was  finishing  pants. 

The  finishing  of  pants,  crocheting  on  ladies'  undervests,  making 
children's  dresses,  nightgowns,  overalls,  etc.,  does  not  include  all 
the  work  carried  on  in  tenement  workrooms.  There  is  a  consid- 
erable number  of  other  industries  carried  on  in  dwelling  houses, 
among  which  may  be  mentioned  the  making  of  artificial  flowers, 
baseballs,  paper  boxes,  cigars  and  cigarettes  and  home  laundries. 
In  one  house  1  found  an  old  Italian  engaged  in  cracking  nuts  for 
fruit  stands.  The  condition  and  appearance  of  the  little  closet- 
like room  were  not  calculated  to  whet  one's  appetite  for  fruit- 
stand  nuts.  Of  all  the  above-mentioned  tenement-house  indus- 
tries, that  of  wearing  apparel  is  the  only  one  which  is  carried  on 
under  supervision. 

Protective  legislation  in  the  line  of  regulating  hours  of  work  and 
employment  of  minors  cannot  be  enforced  in  these  home  indus- 
tries. The  amount  of  work  done  by  the  women  is  regulated  only 
by  the  quantity  they  can  get  and  by  their  physical  endurance. 
One  woman,  for  example,  in  addition  to  her  housework  and  the 
care  of  three  children,  has  to  work  from  fourteen  to  fifteen  hours  a 
day  on  the  sewing  machine  in  order  to  make  one  dozen  pairs  of 
overalls,  for  which  she  gets  seventy-five  cents.  Out  of  this  pit- 
tance she  pays  for  the  delivery  of  the  goods  both  ways.     Her 


1 


LINENTHAL. 


33 


earnings  support  the  whole  family,  consisting  of  an  alcoholic, 
shiftless  husband  and  three  children.  Not  only  do  the  women 
work  excessively  long  hours,  but  in  the  evening  other  members  of 
the  family  are  drafted  into  service.  The  vitality  and  powers  of 
resistance  of  the  tenement  workers  are  thus  lowered  by  the  un- 
sanitary conditions  of  the  homes  and  by  the  excessively  long  hours 
of  work.  They  fall  an  easy  prey  to  all  forms  of  disease,  and  es- 
pecially to  contagious  diseases,  and  become  a  public  menace. 

To  protect  the  public  against  the  spread  of  contagious  diseases 
that  may  occur  in  any  of  the  tenement  workrooms,  the  bulletins 
of  contagious  diseases  reported  to  the  Boston  Board  of  Health  are 
examined  daily.  In  case  disease  occurs  in  any  of  these  workrooms, 
the  premises  are  visited  and  steps  are  taken  to  guard  against  its 
spread.  There  is  always,  however,  the  danger  of  unreported  cases. 
For  example,  a  mild  case  of  scarlet  fever  or  diphtheria  may  run  its 
course  without  a  physician  being  called  in  and  the  case  may  re- 
main unreported.  Moreover,  unreported  cases  of  tuberculosis  un- 
doubtedly exist  among  many  of  the  families  of  tenement  workers. 

There  is  also  the  danger  of  exposing  clothing,  in  tenement  work- 
rooms, to  the  contagious  matter  of  certain  skin  diseases  which 
are  quite  common  among  the  tenement  dwellers.  As  these  are 
not  reported  there  is  no  way  of  detecting  them,  unless  accidentally 
found  in  the  course  of  inspection.  As  a  matter  of  fact  a  number 
of  such  diseases  have  been  found,  and  in  every  instance  work  on 
the  premises  has  been  stopped  until  all  danger  from  their  spread 
has  ceased.  From  July  25,  1907,  to  May  i,  1908,  1,455  visits  were 
made  to  tenement  workrooms.  During  that  period  sixty-three 
cases  of  contagious  diseases  reported  from  these  workrooms  were 
investigated. 

I  have  briefly  described  the  general  conditions  under  which 
men's  clothing  is  manufactured,  both  in  the  shop  and  in  the  tene- 
ment workroom,  and  have  indicated  the  dangers  to  the  operatives 


34 


TUBERCULOSIS    IN    MASSACHUSETTS. 


as  well  as  to  the  public  from  clothing  exposed  to  infectious  ma- 
terial. I  have  also  indicated  in  a  general  way  the  methods  used 
to  guard  the  public  health  against  the  spread  of  diseases  occurring 
in  the  tenement  workroom. 

As  regards  the  improvement  of  sanitary  conditions  in  tailor 
shops,  it  may  be  stated  that  efforts  are  made  to  enforce  strictly 
the  requirements  of  the  law.  Many  of  the  shops  have  been  re- 
plastered,  whitewashed  and  renovated  in  other  ways,  and  a  large 
number  have  been  cleaned.  To  May  i,  1908,  four  hundred  and 
forty-one  visits  were  made  to  two  hundred  and  seventy  work- 
shops where  clothing  is  manufactured,  and  three  hundred  and 
sixty-seven  written  orders  were  issued.  In  one  hundred  and 
seventy-three  reinspected  before  May  i,  the  orders  had  been 
complied  with.  The  law  in  regard  to  spitting  and  providing 
receptacles  for  spitting  is  receiving  special  attention.  All  this, 
however,  is  not  sufficient.  What  is  of  far  greater  importance 
is  the  education  of  the  employers  as  well  as  their  employees  to  the 
necessity  of  the  simplest  sanitary  measures.  This  is  by  no  means 
an  easy  task.  One  meets  with  a  general  indifference  and  apathy, 
quite  frequently  with  obstinacy  and  antagonism  to  the  enforce- 
ment of  sanitary  measures.  Of  still  greater  importance  is  the 
need  of  interesting  the  wholesale  manufacturer,  and  creating  in 
him  a  sense  of  responsibility  as  to  the  conditions  under  which  his 
clothing  is  manufactured. 

The  contract  system  which  prevails  in  the  clothing  industry  is 
at  the  root  of  the  evil.  The  clothing  manufacturer  has  the  goods 
cut  on  the  premises  by  people  in  his  employ.  After  the  cut  ma- 
terial is  handed  over  to  the  contractor  the  manufacturer  concerns 
himself  but  little  with  the  conditions  under  which  the  goods  are 
made.  In  fact,  this  system  puts  a  premium  on  the  filthy  tailor 
shop.  In  the  close  competition  existing  among  the  small  con- 
tractors, the  one  who  has  his  shop  in  an  old,  neglected  building 


LINENTHAL.  35 

can,  in  consequence  of  smaller  expenses,  make  the  goods  for  a 
smaller  compensation,  and  have  the  advantage  over  the  one  who 
is  in  a  clean  building,  with  a  higher  rental.  The  competition 
among  the  contractors  is  extremely  keen;  they  earn  a  mere  pit- 
tance, often  less  than  some  of  their  employees.  It  can  hardly  be 
expected  that  in  the  struggle  to  eke  out  a  mere  existence  any  at- 
tention will  be  given  to  matters  of  sanitation.  A  shifting  of  the 
responsibility  from  the  contractors  to  the  wholesale  manufacturers 
would  vastly  improve  conditions.  This  can  best  be  accomplished 
by  acquainting  the  public  with  the  existing  conditions  and  by 
creating  a  demand  for  cleaner  clothing. 

To  summarize  briefly:  the  inadequate  rate  of  wages,  the  exces- 
sive hours  of  labor,  the  unsanitary  state  of  the  shops,  make  of  our 
clothing  industry  a  sweating  industry,  with  all  the  predisposing 
factors  of  tuberculosis  in  full  operation. 

Before  concluding  I  desire  to  call  attention  to  the  present  inad- 
equate methods  of  supervising  persons  ill  with  tuberculosis.  Every 
person  so  afflicted  who  is  reported  to  the  Boston  Board  of  Health  is 
visited  by  a  physician  of  the  Board,  and  the  family  is  instructed  as 
to  what  measures  should  be  taken  to  guard  against  infection.  But 
the  supervision  of  the  patient  at  his  work,  though  fully  as  impor- 
tant, is  entirely  omitted.  Every  tuberculous  employee  should  be 
visited  at  his  work  in  the  factory,  and  the  employer  or  foreman 
instructed  as  to  what  precautions  should  be  taken  to  guard  the 
health  of  the  other  employees.  The  great  difficulty  at  present  in 
carrying  out  such  a  supervision  is  one  of  our  own  making.  We 
have  been  emphasizing  the  contagious  nature  of  tuberculosis  and 
thus  creating  a  dread  of  the  disease.  A  person  afflicted  with  it, 
however  clean  he  may  be,  is  regarded  as  a  pest  by  both  employer 
and  employees,  and  they  do  not  want  him  in  the  shop.  Consider- 
ing that  the  largest  number  of  consumptives  have  to  remain  at 
their  work,  this  unwarranted  dread  of  having  them  in  the  factory 


36  TUBERCULOSIS    IN    MASSACHUSETTS. 

or  workshop  is  a  tremendous  hardship.  Moreover,  it  is  a  very 
powerful  motive  to  conceal  the  disease,  and  prevents  the  person 
afflicted  from  taking  any  precautionary  measures  which  would  in 
any  way  indicate  that  he  is  tuberculous.  As  long  as  he  spits  on 
the  floor,  for  example,  he  can  remain  quietly  at  his  work  without 
being  molested;  should  he,  however,  take  any  precautions,  such 
as  using  a  sputum  cup,  or  having  a  separate  receptacle  for  spit- 
ting, suspicion  is  immediately  aroused,  and  he  is  in  danger  of 
losing  his  position. 

in  our  preaching  about  the  dangers  and  contagiousness  of 
tuberculosis  let  us  emphasize  a  little  more  the  fact  that  a  person 
ill  with  this  disease,  who  has  clean  personal  habits,  may  attend  to 
his  work  without  endangering  his  fellow  workmen.  The  education 
of  the  public  along  these  lines  will  not  only  render  justice  to  the 
consumptive,  but  will  enable  us  to  supervise  him  at  his  work  in 
the  factory  and  workshop. 


PETERS.  37 


Chapter  v. 

BOVINE  TUBERCULOSIS  IN  MASSACHUSETTS.  A  HISTORY  OF 
THE  EARLIER  AGITATION  CONCERNING  IT,  AND  EFFORTS 
OF  THE  STATE  FOR  ITS  ERADICATION  AND  CONTROL. 

Austin  Peters,  M.R.C.V.S. 

To  the  late  Noah  Cressy,  M.D.,  V.S.,  Ph.D.,  of  Hartford,  Conn., 
is  due  the  credit  of  the  first  attempt  to  call  the  attention  of  the 
farmers  of  Massachusetts  to  the  nature,  importance  and  serious- 
ness of  bovine  tuberculosis.  As  a  speaker  at  several  farmers' 
institutes  in  the  western  part  of  the  State  in  the  winter  of  1879 
and  1880,  held  in  western  Worcester,  Hampshire  and  Hampden 
counties,  he  first  started  the  agitation  against  this  disease.  His 
addresses  created  quite  an  excitement  for  the  time  being  among  the 
farmers  in  the  localities  where  these  institutes  were  held,  and  were 
reported  quite  extensively  in  the  "Springfield  Republican"  in 
January  and  February,  1880,  but  attracted  very  little  attention 
beyond  this,  and  the  excitement  soon  subsided. 

The  report  of  the  first  farmers'  institute  at  which  Dr.  Cressy 
(who  at  that  time  resided  at  Amherst)  spoke  is  in  the  "Springfield 
Republican"  of  January  30,  1880.  The  article  is  headed  "A 
Rural  Sensation,"  and  is  an  account  of  a  meeting  held  at  Warren 
the  previous  day,  where  he  gave  a  lecture  on  "The  Diseases  of 
Farm  Animals,"  among  which  he  included  tuberculosis  in  cattle. 
Among  other  things  he  said  that  the  herd  of  cattle  at  the  Massa- 
chusetts Agricultural  College  was  infected  with  tuberculosis,  and 
that  the  trustees  were  allowing  cattle  of  various  pure  breeds  to  be 
bred  there,  and  permitting  the  progeny  to  be  sold  to  the  farmers  of 
the  State  for  the  purpose  of  improving  their  stock,  whereas  in 
reality  animals  were  being  sold  that  were  infected  with  a  dangerous 


28  TUBERCULOSIS    IN    MASSACHUSETTS. 

disease,  which  in  this  way  was  being  disseminated  among  the  herds 
of  the  Commonwealth. 

A  sensation  was  created  during  the  lecture  by  the  appearance  of 
a  Mr.  Paige  of  Hardwick,  in  a  wheeled  chair,  who  told  how  he 
bought  three  Ayrshire  heifers  from  the  Agricultural  College  in  the 
spring  of  1877,  that  in  November,  1879,  ^^  ^^^  ^^^  killed  for  beef 
and  found  her  badly  diseased,  and  that  he  attributed  his  paralysis 
and  also  a  blood  poisoning  in  his  children  to  the  use  of  the  milk 
from  these  heifers.  He  also  showed  specimens  from  the  side  of 
one  of  these  heifers,  which  Dr.  Cressy  said  were  lesions  of  tubercu- 
losis of  long  standing.  He  also  gave  it  as  his  opinion  that  Mr. 
Paige's  paralysis  and  the  sickness  in  his  children  might  have  been 
caused  by  the  use  of  milk  from  tuberculous  cows.  Dr.  Cressy  also 
referred  to  an  auction  sale  of  cattle  at  the  Agricultural  College 
during  the  previous  summer,  and  the  possible  harm  to  the  herds  of 
the  State  by  the  dissemination  of  these  animals. 

The  report  of  the  meeting  also  conveys  the  idea  that  Dr.  Cressy, 
who  had  formerly  been  Professor  of  Veterinary  Science  at  the  Agri- 
cultural College,  had  severed  his  connection  with  the  institution  on 
account  of  differences  of  opinion  between  himself  and  some  of  the 
members  of  the  faculty  upon  the  question  of  bovine  tuberculosis. 
The  "Springfield  Republican"  of  January  31,  1880,  quotes  Prof. 
Levi  Stockbridge,  who  had  been  at  the  college  thirteen  years,  as 
saying  that  the  college  never  bred  an  animal  that  had  tuberculosis 
there  or  developed  it  within  two  years  of  the  time  it  was  sold; 
furthermore,  that  the  statement  that  Dr.  Cressy  left  the  college 
because  he  disagreed  with  some  of  the  faculty  on  the  presence  of 
tuberculosis  in  the  college  herd  "is  an  unmitigated  and  outrageous 
falsehood."  Professor  Stockbridge  is  also  reported  as  saying  that 
"the  disease  is  only  consumption,  and  may  attack  any  breed  of 
cattle  in  any  part  of  the  country;  that  the  milk  is  healthy  until 
the  animal's  constitutional  vigor  is  utterly  reduced;    and  that 


PETERS.  39 

Mr.  Paige's  statement  that  the  milk  gave  him  paralysis  is  pre- 
posterous." 

The  "Springfield  Republican"  of  February  4,  1880,  has  a  short 
interview  with  Dr.  Cressy,  in  which  he  speaks  of  a  cow  sold  to  a 
farmer  at  South  Amherst,  at  the  auction  held  early  in  the  sum- 
mer of  1879,  afterward  killed  at  the  slaughterhouse  and  found  to 
be  badly  diseased  with  tuberculosis.  It  also  mentions  that  two 
other  Amherst  farmers,  who  were  at  the  auction  with  the  intention 
of  buying,  did  not  bid  on  any  animals  because  Dr.  Cressy,  who  was 
present,  advised  them  not  to. 

In  another  column  on  the  same  date  is  a  short  editorial,  advising 
that  the  college  authorities  should  court  a  most  searching  investi- 
gation, with  a  view  to  either  disproving  Dr.  Cressy's  assertions, 
or,  if  true,  to  setting  matters  right. 

The  "Springfield  Republican"  of  February  5,  1880,  has  a  report 
of  a  farmers'  institute  at  East  Longmeadow,  at  which  Mr.  W.  H. 
Bull  of  West  Springfield  read  a  paper  on  "The  Farmers'  Duty  to 
the  Massachusetts  Agricultural  College,"  after  which  Mr.  Phineas 
Stedman  of  Chicopee,  a  trustee  of  the  college,  spoke  of  the  Paige 
cattle,  saying  they  were  sold  to  Mr.  Paige  in  1877  and  might 
have  become  diseased  since;  that  he  had  bought  cattle  from  the 
Agricultural  College  and  put  them  in  his  own  herd  and  never  found 
any  that  were  not  healthy. 

An  account  of  a  farmers'  institute  held  at  the  town  hall  in  Brook- 
field,  February  5,  1880,  is  contained  in  the  "Springfield  Republi- 
can" of  February  6,  1880.  This  meeting  was  largely  attended,  as 
Dr.  Cressy's  previous  lecture  at  Warren  had  attracted  a  good  deal 
of  attention.  Professor  Stockbridge,  then  Professor  of  Agriculture 
at  the  Massachusetts  Agricultural  College,  was  present  and  took 
the  platform  early  in  the  proceedings.  He  had  a  newspaper  with 
a  report  of  Dr.  Cressy's  previous  lecture  in  his  hand,  and  read 
passage  after  passage  of  Dr.  Cressy's  statements  concerning  the 


40  TUBERCULOSIS    IN    MASSACHUSETTS. 

college  herd  and  the  sale  of  diseased  animals  from  it,  and  asked 
him  as  he  read  each  sentence  if  he  (Dr.  Cressy)  ever  made  any 
such  statement,  and  as  each  question  was  asked,  Dr.  Cressy 
would  shake  his  head.  As  a  matter  of  fact,  Dr.  Cressy's  state- 
ments concerning  the  condition  of  the  college  herd  and  the 
danger  to  other  herds  by  the  introduction  of  cattle  from  it  into 
them  were  correct.  At  that  time  a  cat  could  not  be  kept  in  the 
cattle  barn  at  the  Massachusetts  Agricultural  College  without  de- 
veloping a  cough,  becoming  emaciated  and  pining  away  in  a  few 
months.  Dr.  Cressy  should  have  maintained  the  position  he  took 
at  first,  but  evidently  lacked  the  courage  to  do  so.  After  Professor 
Stockbridge  finished  his  remarks  Dr.  Cressy  gave  a  very  good  talk 
on  bovine  tuberculosis,  its  nature  and  the  danger  from  it  to  the 
herds  of  the  State,  refraining,  however,  from  any  allusion  to  the 
condition  of  the  herd  at  the  State  Agricultural  College. 

This  seems  to  have  been  the  end  of  the  agitation  regarding  bovine 
tuberculosis  in  Massachusetts  so  far  as  Dr.  Cressy  was  concerned. 
What  he  said  did  not  carry  a  great  deal  of  weight  for  the  reason 
that  the  farmers  thought  him  a  disgruntled  individual,  who  was 
endeavoring  to  injure  the  college  because  he  had  been  dismissed 
from  the  faculty  a  few  years  before,  at  a  time  when  the  trustees  of 
the  college  had  to  economize  and  decided  that  the  position  he  held 
could  better  be  dispensed  with  at  the  time  than  any  other.  If  it 
had  not  been  for  the  prevailing  idea  that  he  was  airing  a  grievance, 
which  discredited  his  endeavors,  much  good  might  have  come 
from  the  agitation  he  started.  Cressy's  ideas  were  evidently 
largely  taken  from  Walley's  "Four  Bovine  Scourges,"  and  were 
decidedly  in  advance  of  the  times.  In  his  "  Four  Bovine 
Scourges,"  published  several  years  before  Koch's  famous  dis- 
covery, Walley  includes  tubercle  with  the  other  three  great  con- 
tagious diseases  of  cattle,  viz.,  contagious  pleuropneumonia,  foot 
and  mouth  disease,  and  rinderpest.     In  the  preface  to  his  work  he 


PETERS.  41 

speaks  of  these  four  diseases  as  being  of  "more  importance  to  the 
stock  owner  than  all  the  other  ills  to  which  bovine  flesh  is  heir." 
He  also  says  that,  while  "the  three  first-mentioned  diseases  are 
only  too  well  known,  the  last  (tubercle)  is  less  perfectly  so,  even, 
it  may  be  said,  to  the  veterinary  surgeons." 

He  further  expresses  his  belief  in  the  communicability  of  tuber- 
culosis from  one  animal  to  another,  the  danger  to  man  from  the 
use  of  milk  and  meat  from  tuberculous  animals,  and  his  opinion 
that  tuberculosis  is  identical  in  man  and  the  lower  animals.  He 
quotes  from  the  experiments  of  Villemin,  Gerlach,  Viseur,  Grad, 
Zundel  and  other  veterinary  and  medical  authorities  in  support  of 
his  views. 

In  his  lectures  at  the  farmers'  institutes  Dr.  Cressy  simply 
voiced  Walley's  opinions,  and  the  views  he  then  expressed  were  no 
less  true,  nor  did  they  differ  from  the  views  held  by  many  scientific 
men  at  the  present  time,  but  they  were  not  then  generally  accepted 
as  true  by  the  medical  profession,  because  they  lacked  the  conclu- 
sive proof  later  furnished  by  Koch  when  he  announced  to  the  world 
his  discovery  of  the  tubercle  bacillus.  There  were  a  few  faint 
echoes  following  the  agitation  started  by  Cressy,  although  nothing 
more  was  heard  from  him  personally.  The  "Springfield  Repub- 
lican" of  February  9,  1880,  mentions  the  report  of  the  trustees 
of  the  Massachusetts  Agricultural  College  for  the  year.  The  part 
relating  to  the  college  herd  reads  in  part  as  follows:  — 

That  from  the  most  thorough  investigation  we  have  been  able  to  make,  the 
statement  that  disease  has  been  propagated  by  the  sale  of  cattle  from  the  college 
farm  is  absolutely  false,  and  we  ask  that  the  matter  be  referred  to  the  commis- 
sioners of  contagious  diseases  for  a  most  rigid  investigation. 

There  are  two  or  three  other  references  to  the  matter  in  later  is- 
sues of  the  "  Springfield  Republican,"  only  one  of  which  it  is 
necessary  to  quote.  The  "Springfield  Republican,"  February  12, 
1880,   reports   a   farmers'    institute   at  Northampton,  at  which 


42  TUBERCULOSIS    IN    MASSACHUSETTS. 

Professor  Stockbridge  spoke.  At  the  close  of  the  meeting  resolu- 
tions endorsing  the  work  of  the  college  were  passed,  one  of  which 
was  as  follows :  — 

Resolved,  We  believe  the  reports  of  the  disease,  tuberculosis,  exaggerated,  and 
the  attempt  to  connect  the  college  with  it  unjust. 

The  Cattle  Commissioners  in  their  report  to  the  Legislature  of 
Massachusetts,  January  7,  1881,  refer  to  bovine  tuberculosis  as 
follows :  — 

Owing  to  a  prevailing  feeling  that  we  are  liable  to  an  outbreak  of  contagious 
pleuropneumonia,  or  from  ignorance  of  its  mode  of  propagation,  the  Board  are 
frequently  notified  of  supposed  cases  of  this  disease;  but  they  have  always  proved 
to  be  simple  lung  fever,  or  tuberculous  consumption.  Some  of  these  cases  are 
very  severe  and  fatal,  and  cause  no  inconsiderable  loss  to  stock  owners.  A  nar- 
rative of  one  of  them  will  suffice  for  all,  and  may  indicate  some  of  their  causes  and 
means  of  prevention.  Early  in  October  we  were  notified  by  the  selectmen  of 
Grafton,  in  Worcester  County,  that  cattle  at  a  designated  locality  in  that  town 
were  suffering  from  a  supposed  contagious  disease.  Visiting  the  farm  we  found  a 
large  herd  of  generally  very  fine  looking  and  highly  prized  cows.  The  owner  in- 
formed us  that  some  of  them  had  indicated  disease  for  many  months.  One  had 
already  died;  two  more  were  much  emaciated,  and  probably  past  recovery;  and 
three  or  four  others  coughed  more  or  less  severely.  The  symptoms  of  the  sick 
animals  were  such  as  might  exist  in  the  contagious  form  of  the  disease;  but  the 
herd  had  been  on  the  farm  for  a  long  time,  and  it  was  not  known  that  any  of  them 
had  been  in  contact  with  or  infected  by  cattle  from  abroad.  To  make  the  matter 
certain,  one  of  the  sickest  cows  was  appraised  and  slaughtered.  Both  lungs  of  the 
animal  were  found  packed  and  solidified  with  tubercles;  but  there  was  an  entire 
absence  of  those  peculiar  tissue  characteristics  always  found  in  the  contagious 
form  of  lung  disease.  The  facts  elicited  by  careful  inquiry  respecting  the  history 
of  the  herd  and  its  management  satisfied  the  Commissioners  that  the  disease  was 
engendered  on  the  premises.  There  were  about  forty  animals  in  all,  practically  in 
one  stable,  and,  except  in  the  daytime  in  the  summer  season,  they  had  little  exer- 
cise in  the  open  air.  Throughout  the  cold  portion  of  the  year  the  stable  was  closed 
front  and  rear;  the  barn  doors  were  shut  at  all  times;  and  in  the  coldest  weather 
the  temperature  of  the  stable  was  maintained  at  between  sixty  and  seventy  degrees, 
and  practically  no  ventilation  provided,  in  all  other  respects  the  herd  was  cared 
for  in  the  best  manner;  but  in  the  opinion  of  the  Board  proper  sanitary  conditions 
had  been  systematically  disregarded  for  a  long  time,  and  this  was  a  sufficient  cause 
for  the  condition  of  the  herd.     The  fact  that  this  disease  had  been  found  in  three 


PETERS.  43 

or  four  isolated  localities  within  the  last  year  has  been  the  occasion  of  much  excite- 
ment and  alarm  by  sensational  statements  of  its  contagiousness.  That  it  is  so, 
the  best  authorities  are  not  agreed.  Youatt  in  his  work  on  cattle,  published  in 
1840,  says:  "Animals  which  exhibit  decided  symptoms  of  consumption  should  be 
removed  from  the  dairy,  not  because  the  disease  is  contagious,  but  because  it  is 
undeniably  hereditary."  Recent  experiments  have  been  made  to  test  the  con- 
tagiousness of  tuberculosis,  both  by  inoculation  and  the  ingestion  of  tuberculous 
matter;  and  Fleming  says:  "The  facts  elicited  affirm  that  it  may  be  thus  com- 
municated." Several  investigators  in  this  direction  have  failed  to  produce  corrobo- 
rating results,  and  others  say  that  no  results  have  yet  been  reached  of  any  value 
in  this  direction. 

The  question  of  the  contagiousness  and  virulence  of  tuberculosis  is  still  under 
consideration,  and  further  researches  are  necessary  to  elucidate  and  establish 
certain  important  points  respecting  it.  We  have,  therefore,  declined  to  consider 
it  within  the  intent  of  the  law  which  prescribes  our  duties  and  obligations.  During 
the  excitement  occasioned  by  the  supposed  prevalence  of  this  disease,  a  report 
reached  the  Board  of  Agriculture  that  the  cattle  on  the  Agricultural  College  farm 
at  Amherst  were  infected  with  it,  and  the  members,  in  their  capacity  as  overseers 
of  the  college,  passed  a  re.solve  requesting  the  Commissioners  to  make  a  careful 
examination  of  the  stock  and  its  condition.  Complving  with  this  request.  Dr. 
E.  F.  Thayer,  the  veterinarian  of  the  Board,  made  the  examination,  and  reported 
to  the  overseers  that  "  the  appearance  of  the  animals,  without  exception,  was  that 
of  perfect  health.  Not  one  could  be  found  that  required  physical  examination; 
percussion  and  auscultation  were  tried  on  one  without  eliciting  other  than  a  normal 
and  healthy  condition. 

This  portion  of  the  Cattle  Commissioners'  report  for  1880  is  here 
given  in  detail  because  it  seems  to  be  the  first  official  recognition  of, 
or  a  declination  to  recognize,  tuberculosis  among  cattle  in  Massa- 
chusetts, and  this  communication  from  the  Cattle  Commissioners 
was  in  reality  the  result  of  Dr.  Cressy's  agitation  of  the  matter 
during  the  previous  winter. 

The  late  Professor  Stockbridge,  and  also  the  late  Dr.  Josiah  H. 
Stickney  of  Boston,  have  informed  the  writer  that  during  the  cam- 
paign against  contagious  pleuropneumonia  in  1860-66  occa- 
sionally cases  of  bovine  tuberculosis  were  met  with,  but 
little  attention  was  given  to  them;  the  Cattle  Commission  was 
stamping  out    contagious    pleuropneumonia,    and    this    disease 


44  TUBERCULOSIS    IN    MASSACHUSETTS. 

was  not  contagious  pleuropneumonia,  was  not  known  to 
be  contagious,  and  therefore  little  thought  was  given  to  the  few 
cases  met  with. 

In  their  report  to  the  Legislature  dated  January  lo,  1882,  the 
Cattle  Commissioners,  speaking  of  lung  diseases  in  connection  with 
contagious  pleuropneumonia,  write  as  follows:  — 

Inflammation  of  the  lungs  or  tuberculosis  may  be  engendered  in  the  stock  of 
any  farm  by  undue  exposure,  want  of  ventilation  or  confinement  in  damp  and 
filthy  enclosures.  But  contagious  pleuropneumonia,  which  has  symptoms  resem- 
bling those  diseases,  is  the  result  of  contact  with  an  animal  possessing  the  infection, 
or  with  some  object  he  has  infected,  and  is  disseminated  from  animal  to  animal, 
like  smallpox  or  measles  in  the  human  family.  The  appearance  of  lung  disease 
on  remote  and  isolated  farms,  unless  it  can  be  traced  to  contact  with  animals  from 
abroad,  should  cause  no  alarm,  but  should  prompt  the  owners  to  a  careful  hygienic 
examination  of  their  premises,  and  methods  of  stock  management. 

There  is  no  further  mention  of  bovine  tuberculosis  by  the  Mas- 
sachusetts Cattle  Commissioners  in  their  reports  for  four  years, 
but  a  lecture  was  read  at  the  public  winter  meeting  of  the  State 
Board  of  Agriculture,  at  Framingham,  in  December,  1885,  upon 
"Tuberculosis  in  Cattle,"  prepared  by  Dr.  Frank  S.  Billings  of 
Boston.  Dr.  Billings  was,  unfortunately,  not  present  to  deliver 
it  in  person,  hence  there  was  little  discussion  of  the  paper.  As 
this  lecture  was  given  after  the  discovery  of  the  tubercle  bacillus 
by  Koch  it  was  more  in  accordance  with  modern  ideas  than  the 
statements  in  the  former  reports  of  the  Cattle  Commission.  Space 
will  not  permit  a  resume  of  this  paper,  but  it  can  be  found  in  the 
report  of  the  secretary  of  the  Massachusetts  State  Board  of  Agri- 
culture for  1885. 

In  June,  1885,  the  personnel  of  the  Massachusetts  Board  of  Cat- 
tle Commissioners  was  changed;  Dr.  Thayer  and  Mr.  Jordan  re- 
tired and  Mr.  A.  W.  Cheever,  agricultural  editor  of  the  "New 
England  Farmer,"  and  Dr.  J.  F.  Winchester,  a  young  veterinarian 
of  Lawrence  and  a  graduate  of  the  Massachusetts  Agricultural 


PETERS.  45 

College,  were  appointed  to  replace  them.     Professor  Stockbridge 
was  continued  in  office. 

At  a  special  meeting  of  the  State  Board  of  Agriculture,  held  at 
the  town  hall  at  Barre,  Mass.,  November  29,  1886,  called  at  the 
request  of  the  Cattle  Commissioners,  Dr.  Winchester  addressed 
the  meeting,  calling  attention  to  the  presence  of  bovine  tubercu- 
losis in  the  State,  its  hereditary  nature,  transmissibility  and  in- 
sidiousness,  the  difficulty  of  diagnosis,  and  his  inability  to  assist 
owners  of  infected  herds  under  existing  laws.  He  was  followed 
by  Professor  Stockbridge,  who  stated  that  the  Board  of  Cattle 
Commissioners  had  long  known  of  the  existence  of  bovine  tuber- 
culosis in  Massachusetts,  but  that  the  veterinary  colleges  had 
never  agreed  upon  the  question  as  to  whether  it  is  contagious  or 
not.  "There  has  been  a  long  and  acrimonious  dispute  in  relation 
to  it,  and  the  consequence  has  been  that  the  Cattle  Commissioners 
have  never  recognized  it  or  treated  it  as  a  contagious  disease." 
After  considerable  discussion  it  was  decided  that  if  additional 
legislation  regarding  it  were  necessary,  the  Cattle  Commissioners 
were  the  ones  to  recommend  it  to  the  Legislature  and  to  attempt 
to  procure  it.  The  Cattle  Commission  in  its  report  to  the  Legis- 
lature, January  7,  1887,  refers  to  tuberculosis  among  cattle,  its 
nature  and  dangers,  and  in  conclusion  says:  — 

Notwithstanding  all  that  is  certainly  known  of  the  disease  and  the  great  losses 
it  entails,  yet  it  is  surrounded  with  such  obscurity  and  uncertainty,  and  presents 
such  apparently  insurmountable  obstacles  to  its  eradication,  that  we  have  made 
no  direct  attempts  to  combat  it;  but  some  of  our  citizens,  to  rid  their  herds  and 
premises  of  the  pest,  have,  during  the  past  year,  destroyed  many  thousands  of 
dollars'  worth  of  cattle. 

If  the  Cattle  Commission  made  any  attempt  this  year  to  obtain 
legislation  on  bovine  tuberculosis  nothing  came  of  it.  In  their 
report  6f  January  6,  1888,  for  the  year  1887,  the  Cattle  Commis- 
sioners again  speak  of  the  prevalence  of  tuberculosis  among  cattle. 


46 


TUBERCULOSIS    IN    MASSACHUSETTS. 


its  peculiarities  and  the  difficulty  of  eradicating  it  "by  force  of  our 
present  statutes  or  any  appropriation  the  Legislature  would  make." 
It  says  the  disease  prevails  to  about  the  extent  of  the  previous 
year,  but  suggests  that  as  the  veterinary  profession  increases  in 
number  "attention  is  called  to  it  more  and  more,  and  there  is  a 
call  for  more  active  work." 

In  the  report  of  the  Cattle  Commission  of  January  7,  1889,  for 
the  year  1888,  there  is  a  special  report  by  Dr.  J.  F.  Winchester 
upon  tuberculosis,  showing  by  tables  its  prevalence  and  losses  in 
certain  herds  to  which  his  attention  had  been  called.  In  1889 
Dr.  Winchester's  term  expired  and  the  late  O.  B.  Hadwin  of 
Worcester  was  appointed  to  the  vacancy.  Bovine  tuberculosis  is 
briefly  referred  to  in  the  report  for  that  year,  and  it  is  stated 
that:  — 

Should  the  disease  materially  increase  in  those  sections  of  the  State  where  milk 
is  produced  for  town  or  city  markets,  as  a  measure  to  guard  the  public  health  it 
may  become  the  duty  of  the  Commissioners  or  of  local  boards  of  health  to  cause 
the  inspection  of  herds  producing  market  milk,  and  the  removal  therefrom  of  all 
animals  exhibiting  the  slightest  symptoms  of  this  disease. 


Messrs.  Stockbridge,  Cheever  and  Hadwin  continued  on  the 
Board  of  Cattle  Commissioners  until  the  spring  of  1892,  and  as  the 
public  interest  had  now  been  thoroughly  aroused  on  the  question, 
their  reports  for  1890  and  1891  give  the  subject  a  certain  amount 
of  consideration,  although  the  position  taken  is  rather  one  of  not 
unduly  alarming  the  public  or  of  exaggerating  the  danger. 

In  the  report  for  1890  it  is  stated,  in  reference  to  tuberculosis:  — 

Careful  observation  during  the  past  year  fails  to  convince  us  that  this  disease 
is  becoming  more  prevalent;  but  the  published  experiments  of  sundry  investigators, 
the  zeal  of  veterinarians  for  the  public  welfare  or  their  own  personal  interests, 
have  pointed  out  the  methods  by  which  it  is  propagated,  and  newspaper  reporters 
have  aroused  public  attention  to  the  matter  by  sensational  or  erroneous  reports 
of  a  very  few  special  cases.  The  disease  has  been  here  ever  since  white  men  or 
cattle  occupied  the  land. 


PETERS.  47 

The  report  for  1891  exhibits  considerable  ire  against  the  State 
of  Maine  for  prohibiting  the  shipment  within  her  borders  of  neat 
cattle  from  Massachusetts  because  of  the  prevalence  of  bovine 
tuberculosis  within  the  latter  Commonwealth,  and  remarks  that 
the  action  of  Dr.  George  H.  Bailey,  veterinarian  to  the  Maine  Cat- 
tle Commission,  is  unconstitutional,  and  quotes  a  decision  of  the 
United  States  Supreme  Court  in  support  of  this  view  in  reference 
to  Missouri  forbidding  bringing  cattle  infected  with  Texas  fever 
within  her  limits,  "because  it  attempted  to  interdict  or  control 
commerce  between  the  States,  which  was  a  power  conferred  by 
the  Constitution  only  upon  Congress."  Since  then  there  have 
been  other  opinions  of  the  United  States  Supreme  Court,  that  a 
State  can  take  measures  to  protect  itself  from  the  introduction  of 
a  disease  that  may  endanger  the  health  of  its  people  or  live  stock. 

Late  in  1886  or  early  in  the  winter  of  1887  the  writer  of  this 
chapter,  who  v^as  at  that  time  investigating  contagious  bovine 
abortion  for  the  Massachusetts  Society  for  Promoting  Agriculture, 
remarked  to  the  late  Ebenezer  Francis  Bowditch  of  Framingham, 
one  of  the  trustees  of  the  society,  that  it  would  be  very  interesting 
to  investigate  the  danger  from  the  use  of  milk  from  a  tuberculous 
cow.  While  it  was  generally  conceded  that  a  cow  with  tubercu- 
lous udder  gave  off  tubercle  bacilli  in  the  milk,  it  was  suggested 
that  an  investigation  to  show  how  slightly  diseased  a  cow  might  be 
and  yet  be  dangerous  might  be  of  value.  The  trustees  of  the 
society  decided  that  such  an  investigation  would  be  of  value,  and 
determined  to  undertake  the  work.  The  writer,  while  he  was  the 
society's  veterinarian,  advised  that  in  order  to  make  the  results  of 
the  work  carry  the  greatest  possible  amount  of  weight  the  services 
of  a  man  who  had  already  made  a  name  as  a  scientist,  and  whose 
signature  to  a  report  would  secure  immediate  recognition,  should 
be  secured  to  direct  the  experiments  and  prepare  a  report  of  the 
results.     The  services  of  Dr.  Harold  C.  Ernst  of  Boston,  Professor 


48  TUBERCULOSIS    IN    MASSACHUSETTS. 

of  Bacteriology  at  the  Harvard  Medical  School,  were  secured  for 
this  purpose.  A  committee  of  the  trustees  of  the  Society  for  Pro- 
moting Agriculture,  consisting  of  the  late  Thomas  Motley,  its 
president,  the  late  E.  F.  Bowditch,  the  late  Jacob  C.  Rogers,  and 
Gen.  Francis  Henry  Appleton,  was  appointed  to  have  charge  of 
the  work. 

A  farm  was  rented  at  Mattapan,  a  suburb  of  Boston,  as  an  ex- 
periment station,  in  the  spring  of  1887,  where  a  herd  of  tubercu- 
lous cows  was  kept  for  over  three  years,  and  feeding  and  inoculation 
experiments  conducted  and  bacteriological  examinations  of  the 
milk  and  cream  made  at  the  Harvard  Medical  School.  Dr.  Ernst 
supervised  much  of  the  work  and  wrote  the  report,  but  a  great  deal 
of  the  actual  work  was  performed  by  Dr.  Henry  Jackson,  Dr. 
Langdon  Frothingham  and  the  writer  of  this  chapter.  A  report  of 
the  results  of  these  researches  was  presented  to  the  trustees  of  the 
society  in  the  autumn  of  1890,  and  was  later  published  in  book 
form  at  its  expense  under  the  title  of  "  Infectiousness  of  Milk." 

It  was  found  that  milk  from  a  herd  of  tuberculous  cows  contained 
tubercle  bacilli,  as  demonstrated  by  both  microscopical  examina- 
tion and  inoculation  experiments,  and  that  milk  from  these  cattle 
was  capable  of  producing  tuberculosis  in  calves  and  pigs  fed 
upon  it  in  from  33  to  50  per  cent,  of  cases.  Milk-feeding  ex- 
periments were  tried  on  rabbits,  but  with  much  less  positive  re- 
sults, due  no  doubt  to  the  fact  that  these  little  animals  drink  pro- 
portionately less  milk  than  calves  and  pigs.  Examinations  made 
of  city  milk  taken  in  Boston  and  Lowell,  and  inoculation  experi- 
ments tried  on  rabbits,  showed  it  to  be  infected  in  a  few  instances. 

Beside  the  results  of  the  experiments  at  Mattapan  and  examina- 
tions of  milkmen's  milk  the  report  contains  a  voluminous  corre- 
spondence, elicited  by  letters  written  by  Dr.  Ernst  asking  the  views 
of  members  of  the  veterinary  and  medical  professions  on  the  in- 
fectiousness of  milk,  and  reports  from  veterinarians  upon  the  prev- 


PETERS,  49 

alence  of  bovine  tuberculosis  in  various  localities.     Dr.  Ernst  con- 
cludes the  report  as  follows:  — 

I  have  presented,  in  the  preceding  pages,  the  evidence  that  we  have  been  able 
to  collect  upon  the  points  in  regard  to  which  information  seemed  to  be  especially 
needed.  This  evidence  is  sufficient,  it  appears  to  me,  to  warrant  certain  definite 
conclusions,  as  follows:  — 

1.  While  the  transmission  of  tuberculosis  by  milk  is  probably  not  the  most 
important  means  by  which  the  disease  is  propagated,  it  is  something  to  be  guarded 
against  most  carefully. 

2.  The  possibility  of  milk  from  tuberculous  udders  containing  the  infectious 
element  is  undeniable. 

3.  With  the  evidence  here  presented,  it  is  equally  undeniable  that  milk  from 
diseased  cows  with  no  appreciable  lesion  of  the  udder  may,  and  frequently  does, 
contain  the  bacillus  of  this  disease. 

4.  Therefore  all  such  milk  should  be  condemned  for  food. 

The  Massachusetts  Society  for  Promoting  Agriculture  presented 
the  results  of  these  investigations  to  the  Legislature  of  1891,  on 
January  13,  by  petition  asking  for  legislation  to  secure  an  inspec- 
tion of  cattle  in  Massachusetts.  After  a  delay  of  several  months 
the  Legislature  passed  the  following:  — 

Chapter  ii8,  Resolves  of  1891. 

Resolve  providing  for  an  investigation  by  the  state  board  of  agriculture 
into  the  dangers  arising  from  tuberculosis  in  the  food  products  of 

CATTLE. 

Resolved,  That  the  State  board  of  agriculture  be  instructed  to  investigate  and 
ascertain  the  best  methods  to  be  adopted  in  order  to  protect  the  citizens  of  this 
Commonwealth  against  the  dangers  to  human  life  and  health  which  may  arise 
from  the  presence  of  tuberculosis  in  the  food  products  of  cattle,  with  power  to 
employ  expert  assistance,  and  report  in  print  the  result  of  their  investigations  to 
the  next  general  court,  with  such  recommendations  as  they  may  deem  advisable. 
And  for  the  purpose  aforesaid  they  may  expend  such  sum,  not  exceeding  twenty- 
five  hundred  dollars,  as  they  may  deem  necessary,  which  sum  shall  be  allowed 
and  paid  out  of  the  treasury  of  the  Commonwealth.     [Approved  June  1 1,  1891. 

The  appropriation  provided  was  much  less  than  was  recom- 
mended, and  was  so  small  as  to  negative  the  purpose  of  the  resolve, 


50  TUBERCULOSIS    IN    MASSACHUSETTS. 

as  shown  by  the  following  report  of  the  State  Board  of  Agriculture 
to  the  Legislature  of  1892:  — 

In  compliance  with  the  requirements  of  the  foregoing  resolve  the  State  Board 
of  Agriculture  begs  leave  to  submit  the  following  report:  — 

This  resolve  seems  to  look  to  a  report  on  two  distinct  subjects:  first,  as  to  the 
danger  to  human  life  and  health  from  the  food  products  of  cattle;  and  second,  as 
to  how  best  to  protect  the  public  from  such  danger. 

First.  Much  attention  has  been  bestowed  by  scientists  on  this  branch  of  the 
subject,  and  many  thousands  of  dollars  by  individuals,  institutions  and  societies 
in  investigation.  The  Massachusetts  Society  for  the  Promotion  of  Agriculture 
has  expended  a  large  sum  in  experiments  to  prove  how  great  is  the  danger  to  human 
life  and  health  from  the  use  of  milk  of  tuberculous  cows.  The  results  of  these 
experiments  were  made  known  to  the  Legislature  of  1891,  as  were  also  the  discov- 
eries of  other  scientists  in  our  own  and  foreign  countries.  In  view  of  the  results 
of  the  experiments  obtained  at  such  large  expense,  the  State  Board  of  Agriculture 
believes  that  any  further  experiments  and  investigations  that  could  possibly  be 
made  with  the  sum  appropriated  ($2,500)  could  throw  very  little  light  upon  the 
subject.  For  this  reason  no  expense  has  been  incurred.  That  there  is  danger  to 
human  life  and  health  in  the  food  products  of  animals  affected  by  this  disease 
seems  to  be  a  proved  fact.  There  is  also  danger  to  the  life  and  health  of  our  do- 
mestic animals,  arising  from  the  presence  of  these  diseased  animals  among  them. 
How  great  the  danger  is  depends  upon  the  proportion  which  the  number  of  tuber- 
culous animals  bears  to  the  number  of  those  in  health.  It  must  not  be  forgotten 
that  the  danger  to  life  and  health  is  not  alone  from  food  products.  Many  investi- 
gators believe  that  the  greatest  danger  is  from  the  germs  of  the  disease  floating  in 
the  air.  These  germs  come  from  the  dried  sputa  reduced  to  powder.  The  same 
danger  comes  from  the  presence  of  human  beings  affected  with  the  disease.  Many 
alarmists  have  stated  that  the  proportion  of  tuberculous  cattle  is  very  large, — 
some  place  it  as  high  as  25  per  cent,  of  the  whole  number  in  our  State.  However, 
careful  estimates  from  all  sources  of  information  show  that  the  percentage  of 
tuberculous  animals  is  very  much  less  than  that  figure,  probably  not  more  than 
3  or  4  per  cent.  It  is  known  that  the  cattle  of  all  countries  are  subject  to  this 
disease,  and  have  been  so  subject  for  thousands  of  years;  but  it  is  only  recently 
that  it  has  been  recognized  as  the  same  as  consumption  in  man.  It  is  not  believed 
that  the  proportion  of  infected  cattle  in  Massachusetts  is  much  greater  than  in 
other  thickly  populated  countries. 

Second.  How  best  to  protect  the  public  against  the  danger  to  human  life  and 
health,  arising  from  the  presence  of  tuberculosis  in  the  food  products  of  cattle. 
As  there  is  danger,  it  is  highly  proper  that  the  Legislature  should  provide  for  re- 
ducing the  danger  to  a  minimum.  The  trade  brings  large  numbers  of  cattle  from 
other  States  into  Massachusetts,  and  there  is  alwavs  a  likelihood  of  infected  cattle 


PETERS.  51 

being  brought  in.  Cattle  are  always  liable  to  get  the  disease  from  consumptive 
attendants.  Consequently  we  cannot  hope  to  eradicate  this  disease  from  among 
our  cattle.  So  long  as  the  human  family  suffer  from  it  our  cattle  will  be  liable  to 
it;  but  it  may  be  reduced  to  a  minimum.  The  meat  of  cattle  affected  with  this 
disease  should  not  be  used  for  food;  the  milk  from  tuberculous  cattle  should  not 
be  sold  in  the  market;  it  is  not  safe  to  breed  from  such  animals,  and  they  are  con- 
sequently worthless.  The  owners  of  such  animals  would  only  be  too  glad  to  be  rid 
of  them  were  they  prevented  from  selling  their  food  products,  and  if  it  were  not  for 
the  possibility  of  selling  the  animal  to  some  one  who  was  not  aware  of  its  condition. 
So  the  only  value  a  tuberculous  animal  can  have  is  from  the  possibility  of  imposing 
upon  some  one  by  the  sale  of  unhealthy  food  products  or  worthless  animals.  Thus 
the  practical  solution  of  the  problem  seems  to  be  to  find  means  to  prevent  the  trade 
in  such  cattle.  Many  of  the  milk  farmers  of  the  eastern  portion  of  the  State,  where 
all  admit  tuberculosis  to  be  the  most  prevalent,  procure  their  cows  at  the  Brighton 
and  Watertown  markets.  There  are  gathered  for  sale  the  surplus  cows  of  western 
Massachusetts,  Vermont,  New  Hampshire  and  Maine,  as  well  as  many  from  New 
York  and  farther  west.  A  law  providing  for  the  inspection  of  all  cattle  sold  in 
these  markets  by  a  state  inspector  is  recommended.  Along  with  this  provision 
should  go  an  amendment  to  the  contagious  disease  law,  requiring  the  Cattle  Com- 
mission to  order  the  slaughter  and  burial,  without  appraisement,  of  animals  found 
to  be  infected  with  tuberculosis,  in  the  same  manner  in  which  glandered  horses 
are  disposed  of.  Provision  should  be  made  for  a  post-mortem  examination  of  all 
cattle  thus  slaughtered,  sufficiently  thorough  to  determine  whether  or  not  they 
were  tuberculous,  and  in  case  the  post-mortem  failed  to  show  the  presence  of  the 
disease,  provision  should  be  made  for  remuneration  to  the  owner  for  the  damage 
suffered. 

While  the  above  includes  all  that  the  Board  desires  to  recommend,  if  further 
provision  be  deemed  advisable  it  is  suggested  that  state  inspectors  might  be  ap- 
pointed in  different  parts  of  the  State,  not  less  than  one  to  each  county,  whose 
duty  it  should  be  to  examine  neat  cattle  on  application  from  the  owner,  party 
desiring  to  purchase,  or  town  or  city  authorities,  and  give  certificates  that  such 
animals  were  free  from  tuberculosis  when  the  examination  warranted.  Provision 
should  be  made  for  the  pay  of  such  inspectors  from  the  State  treasury  per  diem 
for  the  time  spent,  or  by  a  stated  sum  per  head  of  cattle  examined.  In  order  to 
make  the  work  of  these  inspectors  most  effectual,  they  should  be  appointed  by  and 
work  under  the  direction  of  the  Cattle  Commissioners. 

The  above  report  is  thus  given  in  full  because  many  of  the 
recommendations  made  in  it  were  incorporated  into  law  by  the 
Legislature  of  1892,  and  have  continued  in  force,  with  occasional 
modifications,  until  the  present  time.     Primarily  to  the  Massa- 


52  TUBERCULOSIS    IN    MASSACHUSETTS. 

chusetts  Society  for  Promoting  Agriculture  belongs  the  honor  of 
bringing  to  public  attention  the  prevalence  of  bovine  tuberculosis, 
and  the  dangers  from  the  use  of  meat  and  milk  from  tuberculous 
animals,  and  it  largely  deserves  the  credit  for  final  legislative  action. 
The  Massachusetts  Legislature  of  1892,  ten  years  after  the  dis- 
covery by  Koch  of  the  tubercle  bacillus,  declared  tuberculosis  to 
be  one  of  the  contagious  diseases  of  animals  recognized  by  the 
statutes  of  the  Commonwealth,  and  provided  for  the  killing  of 
diseased  cattle  without  appraisal  or  payment.  It  also  made  the 
law  providing  for  the  appointment  of  inspectors  of  animals  in  the 
various  cities  and  towns  of  the  State  mandatory;  prior  to  this  it 
had  been  permissive  since  1876,  but  only  a  few  municipalities  had 
availed  themselves  of  it.  Later  the  law  was  amended  to  provide 
that  these  appointments  should  be  subject  to  the  approval  of  the 
Cattle  Commissioners;  it  also  provided  that  the  Board  of  Cattle 
Commissioners  could  appoint  inspectors  of  animals  where  cities  or 
towns  refused  or  neglected  to  do  so,  and  that  they  could  remove 
inspectors  for  incompetency  or  just  cause.  In  1893  the  Legisla- 
ture also  enacted  a  law  providing  a  penalty  for  any  city  or  town 
that  refused  or  neglected  to  appoint  an  inspector  or  inspectors  of 
animals  and  provisions.  In  1908  the  Legislature  passed  a  law 
that  one  of  the  inspectors  of  animals  annually  appointed  in  cities 
shall  hereafter  be  a  registered  veterinary  surgeon.  As  a  matter 
of  fact  nearly  all  the  cities  and  larger  towns  already  had  veteri- 
narians for  inspectors  of  animals. 

In  the  spring  of  1892,  at  the  request  of  Gov.  Wm.  E.  Russell, 
the  Cattle  Commissioners,  Messrs.  Stockbridge,  Cheever  and  Had- 
win,  resigned,  and  the  Governor  reappointed  Professor  Stockbridge, 
and  named  to  serve  with  him  two  veterinarians.  Dr.  Charles  P. 
Lyman,  Dean  of  the  Faculty  of  the  Harvard  Veterinary  School, 
and  Dr.  Maurice  O'Connell,  a  veterinarian  living  in  Holyoke, 
who   qualified  May  12  and  immediately  entered  upon   the  dis- 


PETERS.  53 

charge  of  their  duties.  During  their  first  year  in  office  eighty- 
one  head  of  tuberculous  cattle  were  killed  without  appraisal  or 
payment. 

The  Cattle  Commission  of  three  members  continued  as  above 
until  June,  1894,  when  the  Board  was  increased  to  five;  owing  to 
the  increasing  interest  in  bovine  tuberculosis,  and  the  demand  for  a 
greater  amount  of  work,  it  was  decided  that  three  men  were  not 
sufficient  and  that  the  Board  ought  to  be  larger.  Dr.  Frederick 
H.  Osgood,  a  professor  at  the  Harvard  Veterinary  School,  and 
Leander  F.  Herrick  of  Worcester  were  appointed.  The  act  of  the 
Legislature  increasing  the  Commission  to  five  members  also  pro- 
vided that  one-half  the  value  of  neat  cattle  killed  as  tuberculous 
by  state  authority  shall  be  paid  by  the  Commonwealth,  the  ap- 
praisal to  be  based  on  the  value  of  the  animals  for  food  or  milk. 
In  October,  1894,  Charles  A.  Dennen  of  Pepperell  was  appointed  a 
member  of  the  Board,  to  fill  the  vacancy  caused  by  the  retirement 
of  Professor  Stockbridge,  after  twenty-seven  years'  service,  who 
resigned  at  the  end  of  his  term  of  office. 

In  September,  1894,  the  Board  of  Cattle  Commissioners  first  in- 
troduced the  use  of  tuberculin  as  a  method  of  diagnosis,  and 
immediately  instituted  its  use  upon  a  large  scale.  The  tuberculin 
test  was  applied  to  all  the  cattle  quarantined  on  suspicion  by  the 
local  inspectors  of  animals,  also  upon  cattle  brought  into  Massa- 
chusetts from  adjoining  States,  and  a  systematic  testing  of  entire 
herds  was  undertaken,  the  Commissioners  stating  that  it  was  their 
intention  to  test  all  the  herds  in  the  State  and  kill  reacting  animals, 
starting  in  the  southeast  corner.  This  season  the  entire  bovine 
population  of  Nantucket  Island  was  tested,  only  .9  per  cent,  of 
the  cattle  reacting. 

The  assertion  that  the  Commission  intended  a  compulsory  test 
of  all  the  cattle  in  the  State  aroused  a  great  deal  of  opposition  in 
some  quarters.     During  the  autumn  the  local  inspectors  quaran- 


54  TUBERCULOSIS    IN    MASSACHUSETTS. 

lined  3,295  cattle  on  suspicion  of  being  affected|with  tuberculosis, 
of  which  eight  hundred  and  ten  were  found  to  be  tuberculous  by 
means  of  the  tuberculin  test  and  killed;  1,432  head  were  tested 
at  Brighton,  of  which  eighty-nine,  or  6.21  per  cent.,  were  killed 
and  found  tuberculous,  but  there  were  also  twenty-one  killed  in 
which  no  lesions  were  found.  Of  six  hundred  and  sixty-five 
tested  on  Nantucket,  only  six  reacted,  and  the  lesions  in  some  of 
these  were  so  slight  as  to  be  questionable. 

During  1895  the  personnel  of  the  Commission  remained  as  it  was 
in  October,  1894,  after  the  appointment  of  Mr.  Dennen,  and  the 
policy  adopted  the  previous  autumn  continued  unchanged  in  most 
respects.  The  payment  of  half  compensation  for  tuberculous  neat 
cattle  destroyed  was  found  to  be  unsatisfactory  to  the  farmers, 
and  the  law  was  changed  to  allow  the  full  appraised  value  for  each 
animal  killed,  not  exceeding  sixty  dollars  for  any  one  creature, 
provided  the  condemned  animal  had  been  owned  in  the  Common- 
wealth for  six  consecutive  months  prior  to  the  date  of  condemna- 
tion. 

The  Cattle  Commission  continued  to  test  all  cattle  brought  to 
Brighton,  Watertown  and  Somerville  stock  yards  from  without 
the  State,  and  also  all  Massachusetts  cattle  offered  for  sale  at  these 
markets,  except  beeves  for  immediate  slaughter,  calves  under  six 
months  old  and  cattle  intended  for  export,  until  April  30,  when 
the  work  was  relinquished  for  lack  of  funds. 

In  July  an  order  was  adopted  that  cattle  could  be  brought  in 
from  without  the  State  on  permits  issued  by  the  Board,  except 
to  the  stock  yards  at  Brighton,  Watertown  and  Somerville,  where 
they  could  be  brought  without  permits,  as  these  yards  were  con- 
sidered quarantine  stations,  and  cattle  accompanied  by  satis- 
factory certificates  of  tuberculin  test,  made  by  veterinarians  in 
other  States  approved  by  the  Board,  were  released.  This  method 
continued  for  several  years,  and  soon  became  a  farce  and  fraud 


PETERS.  55 

upon  the  public,  as  much  of  the  work  was  done  dishonestly,  to 
please  the  cattle  dealers,  particularly  for  the  drovers  attending 
the  weekly  market  for  milch  cows  at  Brighton. 

The  systematic  testing  of  herds  started  in  Nantucket  the  pre- 
vious year  was  continued,  and  completed  in  Dukes  (the  island  of 
Martha's  Vineyard)  and  Barnstable  counties,  including  2,856 
animals,  of  which  nine  reacted  to  tuberculin  and  were  killed  and 
found  to  be  tuberculous.  In  addition,  seven  hundred  and  ninety- 
five  head  were  condemned  as  tuberculous  that  were  quarantined 
by  the  local  inspectors. 

The  Cattle  Commission  continued  in  1896  as  organized  in  Oc- 
tober, 1894,  with  Dr.  Osgood  as  chairman  and  Dr.  Lyman  as  sec- 
retary, until  October. 

The  Commission's  position  on  tuberculosis  was  very  radical  and 
expensive.  The  inspectors  of  animals  during  the  first  half  of  the 
year,  before  an  appropriation  was  made  for  the  year's  work,  con- 
tinued to  quarantine  cattle  on  suspicion  of  having  tuberculosis, 
and  the  law  provided  that  after  ten  days  from  the  date  each  ani- 
mal was  quarantined  the  State  should  assume  the  expense,  and 
the  Commission  would  not  kill  any  until  an  appropriation  was 
made.  The  result  was  that  when  the  Legislature  made  an  appro- 
priation, early  in  June,  there  were  1,043  head  of  neat  cattle  in 
quarantine,  upon  which  the  State  owed  a  board  bill  of  128,223 .43, 
nearly  as  much  as  the  appraised  value  of  the  animals  in  quarantine. 

The  avowed  intention  of  the  Board  of  Cattle  Commissioners  to 
enforce  a  compulsory  tuberculin  test  of  all  the  neat  cattle  in  the 
State  aroused  a  great  deal  of  opposition  among  the  farmers.  Tu- 
berculin was  a  new  agent,  and  as  such  could  not  be  forced  upon 
cattle  owners  until  more  was  known  about  it  by  them,  as  many 
statements  were  in  circulation  concerning  injurious  effects  pro- 
duced by  it,  such  as  causing  tuberculosis  in  healthy  cattle,  abortion 
and  the  like;  furthermore,  many  owners  of  cattle  were  unable  to 


56  TUBERCULOSIS    IN    MASSACHUSETTS. 

comprehend  that  an  animal  with  a  nodule  or  two  in  a  bronchial 
or  mediastinal  gland  was  a  source  of  danger  to  other  cattle  or  to 
human  life,  or  that  the  flesh  of  such  an  animal  was  unhealthful 
for  human  food.  As  the  result  of  this  opposition  Dr.  John  M. 
Parker  of  Haverhill  was  appointed  a  member  of  the  Board  by 
Governor  Wolcott,  at  the  expiration  of  Dr.  Lyman's  term  of  office, 
in  October,  1896. 

In  December  Dr.  F.  H.  Osgood  resigned  and  Dr.  Austin  Peters 
of  Boston  was  appointed  to  fill  the  vacancy,  and  elected  chairman, 
with  Dr.  Parker  as  secretary.  The  excitement  over  bovine  tuber- 
culosis reached  high-water  mark  in  1896,  when  the  Legislature 
appropriated  $300,000  for  the  use  of  the  Cattle  GDmmission.  Early 
in  the  winter  of  1897  an  appropriation  of  $250,000  was  secured  for 
the  eradication  of  contagious  disease  among  animals.  During  the 
spring  of  1897  many  farmers  in  Middlesex  County  had  their  herds 
tested  by  veterinarians,  at  their  own  expense,  and  the  veterinarians 
reported  reacting  animals  to  the  Cattle  Commissioners,  who  had 
the  animals  appraised  and  killed.  This  led  to  a  raid  on  the  appro- 
priation as  a  result  of  tests  made  on  cattle  over  which  the  Com- 
mission had  no  control. 

Another  extravagant  feature  of  the  law  then  in  force  was  that 
animals  killed  as  diseased  were  deemed  unfit  for  food,  and  hun- 
dreds of  animals  were  thrown  into  the  rendering  tank  and  made 
into  fertilizer,  which,  under  an  intelligent  system  of  meat  inspec- 
tion, might  have  been  passed  as  fit  for  beef. 

The  farmers  who  had  the  testing  done  in  most  cases  had  no  in- 
terest in  an  attempt  to  diminish  the  amount  of  bovine  tuberculosis 
in  the  State,  but  simply  did  it  as  a  matter  of  speculation,  with  the 
idea  of  selling  a  lot  of  old  milked-out  cows  to  the  Commonwealth 
for  more  than  they  were  worth.  In  this  they  were  disappointed 
to  a  certain  extent,  as  more  cows  reacted  than  the  owners  expected, 
and  also  in  many  instances  the  best  ones,  so  as  to  almost  wipe  out 
entire  herds.    This  condition  of  affairs  attracted  the  attention  of 


PETERS.  57 

certain  members  of  the  Legislature,  and  resulted  in  the  appoint- 
ment of  a  special  joint  committee,  April  9,  1897,  ^o  investigate 
the  work  of  the  Cattle  Commission,  with  power  to  employ  experts 
to  make  autopsies  on  the  cattle  from  certain  herds  in  Dracut,  con- 
demned after  private  tests  made  by  veterinarians,  the  committee 
to  report  to  the  Legislature  later. 

The  committee  selected  as  experts  to  make  autopsies  on  con- 
demned cattle,  and  also  the  few  remaining  non-reacting  cattle  in 
certain  herds,  Harold  C.  Ernst,  M.D.,  of  Boston,  Theobald  Smith, 
M.D.,  of  Boston,  George  N.  Kinnell,  M.R.C.V.S.,  of  Pittsfield, 
Dr.  Frank  Billings  of  Grafton,  a  graduate  of  a  German  veterinary 
school,  and  Charles  R.  Wood,  veterinary  surgeon,  of  Lowell. 
Each  wrote  an  independent  report. 

The  legislative  committee  from  the  Senate  and  House  reported 
May  25,  1897.  There  were  two  reports,  one  signed  by  most  of  the 
members,  and  a  minority  report,  signed  by  two  members  of  the 
House.  The  majority  report  favored  more  conservative  methods, 
stated  that  the  Cattle  Commission  should  pay  more  attention  to 
disinfecting  barns  and  stables  where  tuberculous  animals  had  been 
kept,  immediately  upon  their  removal,  and  before  new  animals 
were  introduced.    The  majority  report  continued  as  follows:  — 

From  our  observations  at  the  investigation  we  hold  that  the  Board  of  Cattle 
Commissioners  should  at  once  take  into  consideration  modifications  of  the  law 
relative  to  the  condemnation  of  cattle  by  tuberculin  test  alone,  that  is,  upon  the 
request  of  owners  of  cattle  for  such  testing  of  their  herds.  If  cattle  are  to  be  con- 
demned or  regarded  as  suspicious  animals  only  after  they  show  signs  of  disease, 
it  is  a  question  as  to  the  propriety  or  equity  of  the  State  paying  full  value  for  those 
that  are  actually  diseased.  This  proposition  we  respectfully  refer  to  the  considera- 
tion of  the  next  General  Court,  trusting  that  the  Board  of  Cattle  Commissioners 
will,  in  the  meantime,  consider  the  same  question  and  offer  recommendations  in 
their  annual  report. 

We  believe  that  the  Legislature  should  at  once  deal  with  the  matter  of  indis- 
criminate tuberculin  tests.  We  recommend  that  all  testing  of  cattle  with  tuberculin 
when  compensation  is  expected  be  limited  to  the  Cattle  Commissioners  or  their 
authorized  agents.  The  Board  of  Cattle  Commissioners  have  already  expended 
more  than  $160,000  of  the  total  appropriation  of  $250,000,  made  earlier  in  the 


58  TUBERCULOSIS    IN    MASSACHUSETTS. 

session.  If  they  are  compelled  to  kill  all  reacting  animals  and  allow  full  compen- 
sation for  the  diseased  cattle  the  remainder  of  the  appropriation  will  soon  be  ex- 
hausted. There  will  then  be  no  money  for  the  prosecution  of  the  regular  work  of 
the  Commission  or  the  slaughter  of  those  animals  reported  by  the  local  inspectors 
as  suspicious  cases,  and  which  are  really  the  most  dangerous  animals  to  the  health 
and  comfort  of  the  general  public.  The  Commissioners  are  not  allowed  to  exceed 
their  appropriation,  hence  all  their  work  must  stop  when  their  money  gives  out. 
We  earnestly  recommend  the  immediate  passage  of  the  following  act:  — 

COMMONWEALTH  OF   MASSACHUSETTS. 

In  the  Year  One  Thousand  Eight  Hundred  and  Ninety-seven. 

An  Act   relative  to  the  payment   of  compensation   from   the  state   treasury  on  ac. 

COUNT   OF   cattle   INFECTED   WITH   TUBERCULOSIS. 

Be  it  enacted  by  the  Senate  and  House  0/  Representatives  in  General  Court  assembled,  and  by  the 
autJiority  of  the  same,  as  follows: 

Section  i.  No  person  or  persons  having  animals  tested  with  tuberculin  shall  be  entitled  to  com- 
pensation from  the  state  for  any  animals  that  react  to  the  tuberculin  test  unless  such  testing  be  done 
by  the  state  board  of  cattle  commissioners  or  their  authorized  agents  acting  as  such  at  the  time  of  the 
test,  and  such  testing  must  be  subject  to  the  supervision  and  control  of  the  state  board  of  cattle  com- 
missioners. 

Section  2.     This  act  shall  take  effect  upon  its  passage. 

We  submit  with  this  report  the  reports  made  by  the  experts  attending  the  post- 
mortem examinations  of  these  cattle. 

The  above  proposed  legislation  was  immediately  acted  upon, 
and  became  law  June  lo,  1897,  insuring  a  complete  control  of  its 
appropriations  to  the  Cattle  Commission  in  the  future.  The 
Legislature  had  already  earlier  in  the  season  passed  an  act  re- 
stricting the  use  of  tuberculin,  which  provided  as  follows:  — 

The  use  of  tuberculin  as  a  diagnostic  agent  for  the  detection  of  the  disease 
known  as  tuberculosis  in  domestic  animals  shall  be  restricted  to  cattle  brought  into 
the  Commonwealth  from  any  point  without  its  limits,  and  to  all  cattle  at  Brighton, 
Watertown  and  Somerville:  provided,  however,  that  tuberculin  may  be  used  as 
such  diagnostic  agent  on  any  animal  or  animals  in  any  other  portion  of  the  State 
upon  the  consent  in  writing  of  the  owner  or  person  in  possession  thereof,  and  upon 
any  animals  condemned  as  tuberculous  upon  a  physical  examination  by  a  com- 
petent veterinarian. 

This  was  approved  March  17,  1897.  This  clause  in  the  law  was 
first  enacted  in  April,  1896,  to  continue  in  force  until  June  i,  1897, 


PETERS.  59 

but  in  March,  1897,  it  was  made  permanent  upon  the  statute  book. 
This  was  due  to  the  opposition  of  the  farmers  to  the  unrestricted 
compulsory  use  of  tuberculin  by  the  Cattle  Commission. 

The  minority  report  of  the  committee  favored  continued  radical 
action,  and  considered  that  if  the  Cattle  Commissioners  had 
made  mistakes  the  fault  was  with  them,  and  not  with  the 
law. 

In  1898  the  Legislature  gave  the  Cattle  Commissioners  "power 
to  make  and  issue  rules  and  regulations  for  the  guidance  of  in- 
spectors of  animals  and  provisions  in  the  inspection  of  meat, 
which  shall  conform  with  the  rules  and  regulations  of  the  United 
States  Bureau  of  Animal  Industry  for  the  inspection  of  meat  for 
export  and  for  interstate  commerce."  This  was  approved  May 
23,  1898.  This  put  an  end  to  the  folly  and  extravagance  of 
making  fertilizer  out  of  meat  fit  for  food.     The  Legislature  of 

1898  appropriated  only  |20,ooo  for  the  use  of  the  Cattle  Com- 
mission. Governor  Wolcott  called  the  attention  of  the  Legis- 
lature to  the  fact  .that  this  appropriation  was  insufficient  to  carry 
out  existing  laws,  and  the  House  then  voted  to  abolish  the  Cattle 
Commission,  in  which,  however,  the  Senate  refused  to  concur. 
The  Governor  then  again  wrote  the  Legislature  a  message,  recom- 
mending a  further  appropriation.  The  House  again  voted  to 
abolish  the  Cattle  Commission;  the  Senate  again  stood  by  it. 
The  Commissioners  decided  to  do  what  they  could  as  individuals 
during  the  remainder  of  the  year,  and  in  this  way  examined  and 
caused  to  be  killed  glandered  horses,  and  kept  up  the  quarantine 
against  out-of-the-state  cattle,  requiring  all  those  brought  in  to 
have  certificates  of  tuberculin  tests,  except  beeves  for  immediate 
slaughter  or  calves  under  six  months  old.     The  Legislature  of 

1899  passed  a  deficiency  appropriation  bill  sufficient  to  pay  the 
members  of  the  Commission  the  arrears  in  their  salaries. 

The  Legislature  of  1899  also  passed  an  act  recodifying  the  laws 


,1 

6o  TUBERCULOSIS    IN    MASSACHUSETTS.  «' 

relating  to  contagious  animal  diseases,  reducing  the  Cattle  Com- 
mission from  five  members  to  three,  and  giving  it  an  appropria- 
tion of  175,000  for  the  current  year.  The  limit  of  value  on  a 
bovine  with  tuberculosis  Vv'as  reduced  from  |6o  to  $40,  and  the 
law  providing  for  the  annual  appointment  of  inspectors  of  animals 
and  provisions  by  the  various  cities  and  towns  of  the  State  was 
changed  to  provide  for  the  annual  appointment  of  inspectors  of 
animals.  The  inspection  of  live  animals  at  the  time  of  slaughter 
and  provisions  was  turned  over  to  the  local  boards  of  health,  the 
inspectors  of  animals  only  having  to  inspect  live  animals  for  con- 
tagious diseases,  quarantine  suspected  cases,  and  make  a  general 
inspection  of  farm  animals  and  premises  where  they  are  kept  when 
ordered  to  do  so  by  the  Cattle  Commission,  which  has  been  or- 
dered annually  in  the  autumn  since  1899.  This  act  was  approved 
May  25,  1899,  and  Governor  Wolcott  appointed  Charles  A.  Dennen, 
Leander  F.  Herrick  and  Dr.  Austin  Peters  members  of  the  Board. 

The  Commission  continued  thus  until  1902,  when,  at  the  sug- 
gestion of  Gov.  W.  Murray  Crane,  who  thought  that  the  State 
had  too  many  cbmmissions,  the  Legislature  abolished  the  Board 
of  Cattle  Commissioners  and  established  in  its  stead  a  Cattle 
Bureau  of  the  State  Board  of  Agriculture,  with  a  chief  appointed 
annually  by  the  Governor  with  the  advice  and  consent  of  the 
honorable  Executive  Council,  who,  by  virtue  of  his  office,  shall 
be  a  member  of  the  State  Board  of  Agriculture.  The  Governor 
then  appointed  Dr.  Austin  Peters  chief  of  the  Cattle  Bureau. 
As  there  is  no  one  in  the  Cattle  Bureau  except  the  chief,  who  has 
the  powers  and  duties  formerly  vested  in  the  Cattle  Commis- 
sion, it  practically  replaces  a  commission  of  three  with  a  single 
commissioner.  This  arrangement  has  remained  in  force  since 
April,  1902. 

During  the  winter  of  1902-03  the  market  at  Brighton  was 
closed  because  of  an  outbreak  of  foot-and-mouth   disease,  but 


PETERS. 


6i 


since  it  was  reopened  in  July  of  the  latter  year  all  out-of-the- 
state  cattle  brought  to  Brighton,  Watertown  and  Somerville  for 
the  weekly  market  upon  which  a  test  is  required  have  been  tested 
by  the  agent  of  the  Cattle  Bureau  in  charge  of  these  yards,  and 
his  assistants,  as  it  was  found  that  much  of  the  testing  outside 
of  the  State,  which  was  done  by  the  veterinarians  for  the 
drovers,  was  not  honestly  performed,  and  the  certificates  in  many 
instances  were  of  no  value.  About  thirteen  or  fourteen  thousand 
cattle,  chiefly  milch  cows,  are  tested  at  the  Brighton  barn  each 
year,  and  reacting  animals,  about  two  hundred  usually,  are 
killed.  Recently  it  has  been  decided  not  to  accept  any  certifi- 
cates of  test  from  veterinarians  outside  of  the  State  on  cattle 
coming  in  on  permits  to  points  outside  of  the  stock  yards  at 
Brighton,  Watertown  and  Somerville,  but  to  have  all  cattle  upon 
which  a  test  is  required  tested  after  arrival  at  their  destina- 
tions by  agents  of  the  Cattle  Bureau.  These  tests  are  made 
free  of  charge  to  citizens  of  Massachusetts,  and  at  cost  to  others, 
as  required  by  chapter  332  of  the  Acts  of  1903. 

The  following  shows  the  amounts  appropriated  for  the  use  of 
the  Cattle  Commission  or  Cattle  Bureau  since  1895,  and  the 
number  of  cattle  killed:  — 


YEAR. 

Amount 
appropriated. 

Number  of 
Cattle  killed. 

Amount  paid 
for  Cattle. 

1896, 

$300,000   00 

5.748 

$189,216  60 

1897,          .            . 

250,000   00 

5,529 

188,534  00 

1898, 

20,000  00 

297 

8,057   61 

1899, 

75,000  00 

785 

17.277   69 

1900, 

50,000  00 

1,423 

30,870   22 

1901, 

■      •      { 

50,000   00 
3,408    I  1  ' 

1        '.341 

27,424    50 

1902, 

I 

58,000   00 
73,000   00 

1,001 

1 

21.137  75 

1903.          . 

4,500   00' 

■.843 

42.454  32 

40,000  00^ 

J 

J  Deficit  appropriation. 


2  Additional  appropriation,  foot-and-mouth  disease. 


62 


TUBERCULOSIS    IN    MASSACHUSETTS. 


YEAR. 

Amount 
appropriated. 

Number  of 
Cattle  killed. 

Amount  paid 
for  Cattle. 

'904 I 

'905 { 

1906,          ....            1 

'907 1 

$65,000  00 
9,500  00' 
67,000  00 
5,000  00* 

66,416  66 
1 1,560  24 
77,000  00 
8,432  60 1 

}        .,658 
}         .,625 

}        '.737 
1        2,030 

$35,456  45 

34. '33  58 
35.952  75 
42,326  60 

Totals, 

$1,233,817  61 

25,017 

$672,842  07 

It  will  be  seen  by  the  foregoing  table  that  for  the  twelve  years 
ending  December  1,  1907,  the  State  of  Massachusetts  has  appro- 
priated the  sum  of  $1,233,817.61  for  the  eradication  and  control 
of  contagious  diseases  among  domestic  animals,  and  that  a  large 
item  of  expense  is  the  cost  of  paying  owners  of  tuberculous  ani- 
mals for  neat  cattle  slaughtered  by  the  state  authority  as  suf- 
fering from  this  disease.  During  twelve  years  25,017  head  of 
tuberculous  cattle  have  been  killed,  for  which  the  State  has  paid 
$672,842.07,  an  average  of  $26.89  P^'*  head. 

It  is  also  shown  how  the  pendulum  has  swung  one  way  and 
then  the  other;  that  in  1896  the  limit  was  reached  when  $300,000 
was  appropriated,  and  in  two  years  the  Legislature  went  to  the 
other  extreme  and  appropriated  but  $20,000,  and  that  the  House 
then  voted  to  abolish  the  Cattle  Gjmmission;  how  later  an  even 
keel  was  reached,  and  since  then  the  appropriation  has  ranged 
from  $50,000  to  $75,000  per  year.  The  combined  appropria- 
tions for  the  years  1896  and  1897  were  nearly  half  of  the  sum  of 
the  appropriations  for  the  twelve  years,  and  $377,750.60  was 
paid  for  11,277  diseased  cattle  in  1896-97,  which  is  more  than 
half  of  the  sum  total  paid  for  25,017  head. 

The  average  price  paid  per  head  for  condemned  animals  in  1897 

'  Deficit  appropriation. 


PETERS.  63 

was  a  little  over  I34,  which  was  the  maximum  average  price  per 
head  reached;  since  then  it  has  been  diminished,  until  the  last  few 
years  the  average  price  paid  per  animal  has  been  between  |20 
and  |2i.  The  reason  for  the  high  prices  paid  in  1896-97  was 
due  to  the  fact  that  all  animals  quarantined  by  the  local  inspectors 
and  many  large  herds  were  tested  with  tuberculin,  and  all  reacting 
animals  killed,  no  matter  how  slightly  diseased  they  might  be, 
and  many  of  these  animals  were  apparently  in  good  physical  con- 
dition, while  at  the  present  time  only  animals  that  show  marked 
physical  evidence  of  disease,  or  that  have  nodulated  udders,  are 
killed,  and  nearly  all  are  condemned  on  a  physical  examination. 
In  1896-97  there  must  have  been,  counting  private  tests, 
fully  ten  thousand  head  of  cattle  tested  with  tuberculin  in  each 
year,  over  half  of  which  reacted,  and  were  killed  and  found  to 
be  diseased. 

The  present  methods  give  the  State  a  tolerably  good  system  of 
dairy  inspection  as  far  as  protecting  the  public  health  from  the 
milk  of  tuberculous  cows  in  Massachusetts  is  concerned,  but  it 
does  not  protect  them  from  the  milk  of  tuberculous  cows  in  Maine, 
New  Hampshire,  Vermont,  Connecticut  or  New  York  State.  While 
much  has  been  done  towards  diminishing  bovine  tuberculosis  in 
some  of  the  adjoining  States,  notably  Vermont,  there  are,  on  the 
other  hand,  localities  from  which  milk  is  shipped  into  Massachu- 
setts where  the  conditions  are  exceedingly  bad. 

It  is  doubtful  if  the  work  at  present  being  carried  on  against 
bovine  tuberculosis  in  Massachusetts  accomplishes  much  in  the 
direction  of  decreasing  the  percentage  of  tuberculosis  among  the 
herds  of  the  State,  as  a  fresh  crop  of  badly  diseased  cattle,  mostly 
cows,  is  harvested  year  after  year;  if  anything,  it  would  appear 
that  there  is  a  slight  increase,  as  the  number  of  condemned  cattle 
has  gradually  increased  a  little,  varying  somewhat  from  year  to 
year,  from  1,423  in  1900  to  2,030  in  1907.     To  do  more  work  and 


64  TUBERCULOSIS    IN    MASSACHUSETTS. 

gain  greater  headway,  larger  annual  appropriations  for  the  use  of 
the  Cattle  Bureau  will  be  needed.  The  greatest  possible  amount 
of  work  is  being  done  with  the  means  available  at  the  present  time. 
If  public  opinion  demands  more  than  is  at  present  being  done,  there 
is  no  doubt  but  what  the  appropriations  will  be  increased  so  as  to 
allow  more  active  and  extensive  measures  being  adopted  for  the 
eradication  and  control  of  bovine  tuberculosis  than  are  at  present 
in  force,  but  it  is  not  at  all  likely  that  the  Commonwealth  of  Mas- 
sachusetts will  ever  return  to  annual  appropriations  for  this  pur- 
pose of  from  1250,000  to  $300,000. 


BOWDITCH.  65 


CHAPTER    VI. 

THE  ORIGIN  AND  GROWTH  OF  THE  SANATORIUM  TREAT- 
MENT OF  PULMONARY  TUBERCULOSIS  IN  MASSACHU- 
SETTS. 

Vincent  Y.  Bowditch,  M.D. 

THE  SHARON  SANATORIUM  AT  SHARON. 

The  Sharon  Sanatorium  in  Sharon,  was  the  first  institu- 
tion of  its  kind  in  New  England  to  be  estabHshed  in  accordance 
with  the  ideas  of  Brehmer  and  Dettweiler  in  Germany  and  later 
of  Trudeau  in  the  Adirondack  Mountains  in  New  York  State.  In 
certain  particulars  the  sanatorium  was  for  several  years  unique. 
Previous  to  its  establishment  in  1890  it  had  been  thought  neces- 
sary to  place  such  institutions  at  a  comparatively  high  altitude, 
at  considerable  distance  from  the  sea,  and  in  climates  less  subject 
than  the  coast  of  New  England  to  sudden  changes  of  temperature 
and  humidity.  The  idea  that  patients  could  be  successfully 
treated  not  far  from  home  had  hitherto  been  thought,  if  not  abso- 
lutely impossible,  at  least  of  such  doubtful  nature  that  the  sug- 
gestion was  at  first  regarded  by  many  as  almost  chimerical. 

In  spite  of  this  skeptical  attitude  on  the  part  of  both  the  medical 
profession  and  the  laity,  and  following  the  teachings  of  the  late 
Henry  Ingersoll  Bowditch,  who  for  many  years  had  constantly 
taught  the  value  of  fresh  air  as  the  most  important  feature  in  the 
treatment  of  pulmonary  disease,  an  appeal  was  made  to  private 
citizens  of  Boston,  and  the  sum  of  about  130,000  was  raised.  The 
town  of  Sharon,  approximately  eighteen  miles  from  Boston  and 
ten  miles  from  the  seacoast,  was  selected  on  account  of  its  favor- 
able situation  on  the  watershed  between  Boston  and  Providence, 
and  because  of  its  porous  soil  and  abundant  supply  of  excellent 


66  TUBERCULOSIS    IN    MASSACHUSETTS. 

water.  Through  the  bounty  of  a  lady  deeply  interested  in  the 
plan,  a  small  farm  of  twenty-three  acres  was  bought,  and  upon  a 
high  knoll  at  an  altitude  of  only  about  two  hundred  and  fifty  feet 
above  sea  level,  sheltered  by  woods  on  the  north,  east  and  west, 
a  commodious  but  simple  building,  suitable  for  nine  patients  and 
the  administrative  staff,  was  erected  in  the  autumn  of  1890.  As 
necessary  adjuncts  to  the  sanatorium,  a  pumping  engine  and  tank 
for  the  water  supply  were  installed  and  a  simple  but  thorough 
method  of  cesspool  drainage  was  arranged,  to  be  changed  in  later 
years  to  a  perfected  form  of  sewage  filter-beds.  The  cost  of  these 
essentials  for  a  sanatorium,  in  addition  to  a  small  amount  of  grad- 
ing and  road-making,  amounted  to  about  $20,000.  The  sum  of 
$10,000  was  therefore  left  for  current  expenses  until  the  object 
and  aims  of  the  sanatorium  should  become  generally  known. 

The  institution  was  opened  on  the  9th  of  February,  1891,  and 
the  first  patient  was  received  on  February  16.  It  was  formally 
incorporated  in  March,  1891,  with  the  legal  title  of  the  "Sharon 
Sanitarium."  '    The  following  directors  and  officers  were  elected :  — • 

Board  of  Directors:  Alfred  Bowditch,  President,  N.  H.  Stone, 
Treasurer,  Reginald  Gray,  L.  Vernon  Briggs,  Miss  Olivia  Y.  Bow- 
ditch,  Miss  Alice  M.  Curtis,  Secretary,  Miss  M.  H.  Denny,  Mrs. 
Horatio  A.  Lamb.  Medical  Directors:  Vincent  Y.  Bowditch, 
M.D.,  Robert  W.  Lovett,  M.D.  Consulting  Physicians:  Henry  I. 
Bowditch,  M.D.,-  Frederick  1.  Knight,  M.D.  Assistant  Physician, 
John  J.  Moran,  M.  D.     Matron,  Mrs.  M.  E.  Small. 

As  the  sanatorium  was  intended  only  for  women  in  the  early 
stages  of  tuberculosis,  of  very  limited  means,  a  uniform  charge  of 
$5  a  week,  exclusive  of  personal  laundry,  was  established.  This 
sum  included  all  medical  services,  medicines  and  board.  The 
same  charge  is  still  adhered  to,  in  spite  of  the  great  increase  in  the 

1  This  name  was  legally  changed  in  1903  to  "  Sharon  Sanatorium,"  as  being  the  more  correct  and 
usually  adopted  title. 

2  Died  in  1892. 


BOWDITCH.  67 

cost  of  living  in  the  past  few  years,  and  in  spite  of  the  fact  that 
the  annual  deficit  is  much  larger  than  formerly. 

The  Sanatorium  has  been  dependent  chiefly  upon  the  public  for 
its  support,  and  in  consequence  of  certain  bequests  has  made 
notable  additions  to  its  buildings.  In  1897  ^  small  infirmary  was 
built  not  far  from  the  main  building,  for  the  reception  of  patients 
who  should  become  very  ill,  or  in  case  of  an  outbreak  of  any  acute 
infectious  disease  requiring  absolute  isolation.  In  1900,  by  the 
bequest  of  Thomas  T.  Wyman,  a  large  wing  was  added,  providing 
separate  rooms  for  ten  patients,  attic  rooms  for  the  servants,  a 
large  treatment  room,  and  a  heating  plant  in  the  basement.  Be- 
tween this  wing  and  the  infirmary,  and  connected  by  a  subway, 
a  cottage  with  apartments  for  the  matron-superintendent  and  for 
the  resident  physician  was  also  added.  The  capacity  for  patients 
has  thus  been  increased  during  the  past  few  years  to  twenty-three 
beds. 

During  the  past  year  extensive  but  simple  alterations  have  been 
made.  Sleeping  balconies  have  been  added  to  the  main  building 
and  wing,  so  that  every  bed  can  be  rolled  out  at  night,  the  patients 
sleeping  in  the  open  air  under  a  canvas  canopy  even  in  the  coldest 
winter  weather.  The  dining-room  has  been  much  enlarged,  with 
marked  increase  of  light  and  air  by  the  insertion  of  a  larger  number 
of  windows  than  before. 

To  the  small  farm,  upon  which  the  buildings  now  stand,  more 
than  one  hundred  acres  of  beautiful  woodland  have  been  added  to 
the  property  by  gift  and  by  purchase.  By  this  the  buildings  are 
shielded  from  the  harshest  winds  and  the  woods  are  being  slowly 
developed  as  a  park  for  the  patients'  use,  the  sale  of  timber  being 
made  a  source  of  income  to  the  sanatorium.  A  few  acres  of  farm 
land  are  used  for  the  production  of  vegetables  sufficient  for  the 
patients'  needs  throughout  the  summer  season,  the  supply  of  pota- 
toes usually  being  sufficient  for  the  whole  year.     Milk  is  obtained 


68  TUBERCULOSIS    IN    MASSACHUSETTS. 

from  an  excellent  herd  of  cows  on  the  Town  Farm  near  by,  which 
is  in  charge  of  an  excellent  Superintendent,  the  animals  being 
occasionally  examined  by  the  State  Inspector. 

The  cost  per  patient  is  one  of  the  difficult  problems  of  such  an 
institution.  All  sanatoria  of  this  nature  are  naturally  compara- 
tively expensive.  If  good  results  are  to  be  obtained,  a  much  larger 
outlay  is  required  for  provisions  than  in  ordinary  hospitals.  The 
fact  that  a  prolonged  stay  is  necessary  for  each  patient  means  that 
the  surroundings  must  be  attractive,  though  not  necessarily  luxu- 
rious, and  entertainment  must  be  afforded  to  relieve  monotony  as 
essentials  in  treatment.  The  class  of  patients  received  at  Sharon 
is  also  a  factor  in  the  expense.  People  of  refinement,  even  if  of 
very  limited  means,  naturally  require  more  than  the  lowest  class 
of  the  poor.  All  these  considerations  have  to  be  taken  into  account 
in  estimating  the  comparative  cost  of  different  institutions.  The 
price  of  board  thus  far  charged  (I5  a  week)  barely  covers  one-third 
of  the  outlay,  and  in  spite  of  earnest  endeavor  to  use  economy  it 
has  hitherto  been  impossible  to  lessen  the  expense  per  capita. 

The  number  of  people  in  the  working  staff  of  the  sanatorium  is 
as  follows:  a  Superintendent  and  Matron  (since  May,  1901,  Miss 
Alice  R.  Hodges),  who  has  charge  of  the  general  administration 
and  of  the  nurses;  a  Resident  Physician  (Dr.  Walter  A.  Griffin 
since  190 1),  who,  with  the  Medical  Director,  has  charge  of  the 
medical  department;  two  nurses;  seven  maids;  and  two  men-of- 
all-work  for  the  stable  and  farm. 

The  experiment  has  been  tried  in  times  past  of  employing  the 
patients  in  the  general  work  of  the  household;  but  for  various 
reasons  this  has  been  found  impracticable,  chiefly  because  not  only 
is  it  apt  to  interfere  with  the  course  of  treatment,  but  because  of 
the  liability  to  illness,  thus  crippling  the  management.  Each 
patient,  however,  is  supposed  to  have  the  care  of  her  own  room, 
unless  the  physical  condition  contraindicates  it. 


I 


^^^HkMM, 


m 


^3?*4fc. 


m 


^W 


'Lr- 


"^'^i. 


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Bil  CCT| 


I 


BOWDITCH.  69 

The  institution  is  free  of  any  debt,  but  is  in  constant  need  of 
funds  to  supply  the  annual  deficit.  An  Auxiliary  Committee  of 
ladies  and  gentlemen  has  been  of  invaluable  service  in  adding  large 
sums  to  the  treasury  by  bazaars  and  other  entertainments.  An 
attempt  is  being  made  to  establish  an  endowment  fund,  and  thus 
far  about  |20,ooo  has  been  obtained  for  that  purpose. 

The  results  obtained  at  Sharon  have  long  since  shown  that  what 
was  started  as  an  experiment  over  seventeen  years  ago  has  justified 
the  belief  that  much  more  can  be  done  near  the  patients'  homes 
than  was  thought  possible  a  comparatively  few  years  ago.  Since 
the  development  of  the  method  of  fresh-air  treatment,  by  which 
the  patients  are  practically  in  the  open  air  nearly  every  minute 
of  the  twenty-four  hours,  summer  and  winter,  the  results  are  even 
more  satisfactory  than  in  the  earlier  days,  when  less  rigorous 
methods  were  in  use.  A  few  statements  are  appended,  showing 
the  results  of  treatment. 

The  Medical  Report  for  March,  1907,  prepared  in  accordance 
with  the  plan  used  by  the  National  Association  for  the  Study  and 
Prevention  of  Tuberculosis,  gives  the  following  results:  out  of 
forty  proven  cases  of  tuberculosis  treated  during  the  year,  nine- 
teen were  discharged  "apparently  cured,"  nine  were  discharged 
"arrested,"  ten  were  discharged  "improved,"  two  were  discharged 
"progressive." 

In  a  paper  entitled  "Subsequent  Histories  of  One  Hundred  and 
Sixty  'Arrested  Cases'  ^  of  Pulmonary  Tuberculosis  treated  at  the 
Sharon  Sanatorium,  1891-1906,"  by  Vincent  Y.  Bowditch,  M.D., 
and  Walter  A.  Griffin,  M.D.,  ^  the  following  facts  are  given:  — 

1  This  use  of  the  term  "  arrested  "  is  in  accordance  with  the  former  method  of  nomenclature  adopted 
at  Sharon.  It  comprises  all  those  cases  who  at  the  time  of  discharge  were  free  of  all  abnormal  out- 
ward symptoms  of  disease,  viz.,  cough,  sputa,  fever,  etc.,  the  general  aspect  and  condition  being  one 
of  apparent  good  health.  By  this  method,  the  term  "  cured  "  or  even  "  apparently  cured  "  is  not  used 
until,  after  a  period  usually  of  many  months,  the  patient  under  ordinar>'  conditions  of  life  has  shown 
no  sign  of  relapse. 

2  Transactions  American  Climatological  Association,  1907,  printed  in  igo8. 


70 


TUBERCULOSIS   IN   MASSACHUSETTS. 


Summary  of  the  Total  Number  of  "Arrested"  Cases,  189 1-1906  inclusive. 

Total  number  "  arrested,"        .  .  .  .  .  .  .160 

Number  still  living  and  well,  most  of  them  wage-earners  or  house- 
keepers,      133=83.0-1-% 

Number  who  have  not  recently  been  heard  of,  but  who  at  last  ac- 
counts were  doing  well,  many  of  them  in  robust  health,  .  ,        6=3.7% 

Number  who  have  since  died,  .         .  .  .  .  .  .21  =  13.0-1-% 

It  should  be  added  that,  of  those  who  died,  the  majority  were 
advanced  cases  in  which  arrest  of  the  disease  was  not  expected. 
Two,  at  least,  died  from  some  cause  other  than  tuberculosis,  and 
others  returned  against  advice  to  unhygienic  surroundings,  and 
relapsed. 

The  present  list  (1908)  of  Directors  and  Officers  of  the  Sanato- 
rium is  as  follows :  — 

Board  of  Directors:  Prof.  William  T.  Sedgwick,  President,  N.  H. 
Stone,  Treasurer,  614  Sears  Building,  Boston,  Mrs.  Charles  A. 
Porter,  Secretary,  Augustus  Hemenway,  Rev.  Edmund  F.  Mer- 
riam,  Arthur  Dehon  Hill,  Mrs.  Henry  P.  King,  Mrs.  Wm.  T.  Sedg- 
wick, Vincent  Y.  Bowditch,  M.D.,  Robert  W.  Lovett,  M.D., 
L.  Vernon  Briggs,  M.D.  Medical  Director,  Vincent  Y.  Bowditch, 
M.D.  Consulting  Physician,  Frederick  I.  Knight,  M.D.  Resident 
Physician,  Walter  A.  Griffm,  M.D.  Superintendent  and  Matron, 
Miss  Alice  R.  Hodges. 

THE   STATE    SANATORIUM    AT   RUTLAND. 

On  June  5,  1895,  pursuant  to  the  provisions  of  chapter  503  of 
the  statutes  of  1895  of  the  Massachusetts  Legislature,  a  bill  was 
approved  for  the  establishment  of  a  so-called  "Massachusetts 
Hospital  for  Consumptives  and  Tubercular  Patients,"  and  a 
Board  of  five  Trustees  was  appointed  by  the  Governor  and 
Council.  This  is  the  first  instance  in  America  of  the  founda- 
tion of  a  state  institution    for    the  treatment    of    tuberculosis. 


BOWDITCH.  71 

The  sum  of  1150,000  was  appropriated  for  the  purpose  of 
purchasing  suitable  land  and  for  the  erection  of  buildings  there- 
upon. 

The  Board  of  Trustees,  composed  of  Fred  B.  Percy,  M.D.,  of 
Brookline,  Alfred  Worcester,  M.D.,  of  Waltham,  and  Messrs. 
John  C.  Hammond  of  Northampton,  A.  W.  Esleeck  of  Holyoke 
and  W.  E.  Parkhurst  of  Clinton,  held  their  first  meeting  for  or- 
ganization on  August  15,  1895. 

After  much  individual  study  of  the  question,  and  after  obtain- 
ing the  opinion  of  many  physicians  throughout  the  State  as  to 
the  best  location  for  such  a  hospital,  a  farm  of  about  two  hun- 
dred acres  in  Rutland,  in  Worcester  County,  fifty  miles  from 
Boston,  at  an  elevation  of  about  eleven  hundred  feet,  was  pur- 
chased, as  having  many  of  the  essentials  for  the  location  of  such 
a  hospital,  and  buildings,  planned  by  the  architect,  W.  Chester 
Chase  of  Boston,  were  erected. 

In  December,  1897,  the  first  report  of  the  Trustees  was  issued. 
It  speaks  of  the  unforeseen  difficulties  of  drainage  and  of  laying 
out  a  long  road  to  reach  the  Sanatorium,  both  requiring  a  larger 
outlay  than  was  at  first  supposed.  The  drainage  was  carried 
through  a  rocky  cut  to  the  west  of  the  hospital  to  a  point  about 
one  mile  distant  onto  lands  six  acres  in  extent  acquired  for  the 
purpose  of  filtration  beds.  At  the  time  of  opening,  therefore, 
no  administration  building  had  been  put  up,  owing  to  lack  of 
sufficient  funds,  and  in  consequence,  the  Superintendent  was 
obliged  to  occupy  a  portion  of  the  hospital  intended  for  other 
purposes.  This  left  a  capacity  of  about  one  hundred  and  seventy- 
five  beds  for  men  and  women,  instead  of  two  hundred  as  originally 
intended.  The  price  of  board  and  treatment  was  fixed  at  50 
cents  a  day  (I3.50  a  week).  This  price  was  not  long  afterwards 
raised  to  I4  a  week,  this  being  the  present  charge  to  all  patients. 
At  first  no  distinction  was  made  as  to  race,  creed  or  age,  although 


72  TUBERCULOSIS    IN    MASSACHUSETTS. 

there  was  a  somewhat  tacit  agreement  that  no  child  under  twelve 
should  be  admitted. 

At  this  time  the  question  was  mooted  of  changing  the  name 
of  the  institution  and  of  converting  its  purpose  from  that  of  a 
hospital  for  advanced  cases  to  that  of  a  sanatorium  for  the  treat- 
ment of  incipient  and  moderately  advanced  cases.  In  the  Trus- 
tees' report  for  1898,  the  success  obtained  at  the  Sharon  Sana- 
torium was  cited  as  an  instance  of  what  could  be  done  for  the 
successful  treatment  of  incipient  tuberculosis  in  Massachusetts, 
and  the  decision  was  made  to  so  change  the  original  purpose  of 
the  bill  as  to  make  the  institution  a  sanatorium  for  hopeful  cases, 
rather  than  a  hospital  for  advanced  cases.  The  wisdom  of  the 
Trustees  in  making  this  decision  can  only  be  fully  estimated 
when  one  realizes  the  intense  interest  which  was  soon  shown  by 
other  communities  throughout  the  United  States,  who  have 
since  followed  the  example  of  Massachusetts  in  erecting  state 
sanatoria. 

Two  specialists  on  pulmonary  diseases  were  chosen  to  act  as 
attending  physicians,  who  should  represent  respectively  the 
regular  and  the  homoeopathic  schools  of  medicine,  in  accordance 
with  the  terms  of  the  original  bill.  Drs.  Vincent  Y.  Bowditch 
and  Herbert  C.  Clapp  of  Boston  were  selected  to  fill  the  positions. 
Their  duties  consisted  in  making  weekly  visits  to  Rutland;  in 
taking  full  charge  of  the  medical  departments,  with  the  privilege 
of  having  assistants  who  should  reside  in  the  hospital;  and  in 
making  weekly  examinations  of  applicants  at  the  Boston  office 
of  the  hospital. 

On  September  23,  1898,  the  hospital  was  formally  opened 
by  Governor  Roger  Wolcott.  The  first  patient  was  received 
October  3,  and  Drs.  Bowditch  and  Clapp  began  their  service. 

Dr.  Walter  J.  Marcley  had  been  previously  chosen  as  Superin- 
tendent, and  Miss  Mary  E.  Thrasher  as  Matron.     In  1900,  by  an 


I 


BOWDITCH.  73 

act  of  Legislature  (statutes  1900,  chapter  192),  the  name  of  the 
hospital  was  changed  to  that  of  the  "Massachusetts  State  Sana- 
torium" in  accordance  with  the  decision  of  the  Trustees  to  ex- 
clude all  far-advanced  and  hopeless  cases  from  the  institu- 
tion. 

During  the  year  1901-02,  at  the  suggestion  of  the  State  Board 
of  Charity,  five  new  buildings  were  added,  —  an  administration 
building,  a  recreation  hall,  a  large  dining-room  and  two  new  wards, 
—  thus  increasing  the  capacity  of  the  institution  to  two  hundred 
and  fifty  beds.  In  consequence  of  the  larger  number  of  patients, 
a  second  medical  assistant  for  the  regular  service  was  appointed 
at  this  time. 

By  statutes  enacted  in  June,  1903,  chapter  445,  and  under 
chapter  75  of  Resolves  of  1904,  after  a  careful  study  of  the  ques- 
tion by  the  State  Board  of  Charity,  provision  was  made  for  the 
addition  of  "four  brick  cottages,"  two  to  be  used  as  general 
wards,  one  as  a  possible  "probation  ward"  and  another  as  an 
"infirmary"  for  twenty  or  thirty  patients  who  might  require 
special  nursing  during  severe  illness.  These  wards  were  com- 
pleted in  1905,  with  the  exception  of  one  spoken  of  as  a  "proba- 
tion ward,"  which,  owing  to  the  unexpected  expense  of  estab- 
lishing a  new  heating  plant,  was  omitted.  The  infirmary  was 
finished  later.  The  capacity  was  thus  increased  to  about  three 
hundred  and  eighty  beds. 

At  this  time,  in  1905,  the  expense  per  capita  was  $8.83  per 
week,  as  against  $9.36  in  1904. 

In  1904  the  Boston  office  was  removed  from  181  Tremont 
Street  to  the  Out-Patient  Department  of  the  Massachusetts 
General  Hospital,  the  duty  of  examining  patients  for  admission 
falling  upon  the  resident  assistant  physicians  of  the  Sanatorium, 
instead  of  the  attending  physicians.  Examining  offices  were 
also  established  in  Worcester,  Lowell,  Springfield,  Fall  River  and 


74  TUBERCULOSIS    IN    MASSACHUSETTS. 

Pittsfield,   special   examiners   having   been   appointed   to   these 

positions. 

In   1905  two  women  members  of  the  Board  of  Trustees  were 

appointed,  making  the  number  seven  in  all. 

In  the  same  year,  at  the  suggestion  of  the  State  Board  of  Charity, 
an  out-patient  department  was  established  at  the  Sanatorium, 
for  the  benefit  of  patients  who  were  boarding  in  the  surrounding 
farm-houses  but  not  connected  with  the  Sanatorium.  Two 
local  physicians  in  Rutland  kindly  consented  to  take  charge 
gratuitously  of  this  department;  but  thus  far,  according  to  the 
Superintendent,  in  his  eleventh  annual  report  (1907),  their  ser- 
vices have  not  been  in  such  demand  as  was  at  first  thought  would 
be  the  case,  there  being  on  an  average  only  eight  or  ten  calls 
weekly.  Most  of  the  work  of  this  department  now  consists  of 
laryngeal  examinations  and  treatments  done  by  the  assistant 
physicians  in  the  Sanatorium. 

In  1906  the  Trustees  decided  to  change  the  form  of  admin- 
istration by  abolishing  the  positions  of  attending  physicians, 
and  by  placing  the  whole  medical  department  under  the  charge 
of  a  Medical  Superintendent  and  his  assistants.  Following  this 
decision.  Dr.  E.  O.  Otis  of  Boston  (who  had  been  chosen  to  fill  the 
place  of  Dr.  Bowditch  after  the  latter's  withdrawal  on  January 
I,  1906)  and  Dr.  H.  C.  Clapp  ceased  to  be  attending  physicians 
and  were  made  consulting  physicians,  to  serve  without  salary. 
Dr.  Frederick  L.  Hills  was  also  chosen  as  Medical  Superintendent, 
in.the  place  of  Dr.  Walter  J.  Marcley,  who  resigned  to  take  charge 
of  the  Minnesota  Sanatorium. 

The  cost  per  capita  during  this  year  again  increased  to  I9.38, 
largely  due,  doubtless,  to  the  general  increased  cost  of  living 
everywhere.  In  1907  this  cost  was  increased  to  |i 0.07,  probably 
due  to  the  same  cause  as  before. 

The  report  for  1904  contains  an  interesting  statement  as  to  the 


BOWDITCH. 


75 


effect  of  the  Sanatorium  upon  adjacent  real  estate  values  and  upon 
the  health  of  the  native  population  of  Rutland.  On  the  assessor's 
books  the  total  valuation  of  the  town  in  1904  was  1704,183;  in 
1895,  before  the  Sanatorium  acquired  any  land,  it  was  1518,180,  — 
a  gain  of  $186,000.  The  number  of  deaths  from  tuberculosis  (ex- 
clusive of  those  who  came  to  the  town  to  be  treated  for  the  disease) 
for  the  whole  time  since  patients  were  first  received,  viz.,  1899  to 
1904,  inclusive,  —  six  years,  —  was  eight;  for  the  six  years  imme- 
diately preceding  (1893  to  1898  inclusive),  eleven;  for  six  years 
1887  to  1892  inclusive,  eleven;  for  six  years  1881  to  1886  inclusive, 
fourteen.  The  town  has  thus  averaged  for  the  last  twenty-four 
years  two  deaths  per  year  from  tuberculosis  in  a  population  averag- 
ing about  one  thousand.  During  the  six  years  previous  to  1904, 
with  increased  population,  the  deaths  from  this  cause  were  less 
than  before. 

A  table  of  comparative  results  expressed  in  percentages  during 
the  first  eight  years  of  the  Sanatorium  is  hereby  appended.  It  is 
taken  from  the  tenth  annual  report  of  November  30,  1906. 

Comparison  of  Percentages  in  the  First,  Second,  Third,  Fourth,  Fifth,  Sixth,  Seventh 

and  Eighth  Years. 


QfC 

e 
* 

9 

a 

© 
0 

M 
9 
9 

9 
9 

9 
9 

9 
9 
9 

e 

0 
a 

f4 

9 
0 

ft 

9 
9 

M 

9 
9 

9 

9 
9 

Per  cent,  of  "  arrested  "  or  "  appar- 
ently cured  "  cases. 

34-28+ 

42-35 

46.12 

48.31 

48-97 

44-8 

33-7 

39-1 

Per  cent,  of  all  classes  of  "  improved  " 

39-36+ 

44.70 

47.64 

44.S1+ 

43 -00+ 

47-7 

58.9 

52.1 

cases. 

Per  cent,  of  "not  improved  "  cases, 

26.04+ 

12.9s 

5-74 

6-73+ 

7.90+ 

7-4 

7-4 

8.8 

Percentage  of  Incipient  Cases  " 

arrested"  or 

"  apparently 

cured 

" 

9 

9 

i 

*4 

9 
9 

9 

9 

9 
9 

9 

9 

9 

« 

9 
9 
p« 
1 

PM 

9 
9 

M 
9 
9 

9 
9 

9 
9 

•N 

M 

9 

9 

9 
9 

4 

9 
9 

PN 

9 
9 
9 

M 
1 

<n 

9 
9 

"  Arrested  "  or  "  apparently  cured," 

64.60 

72.90    73.00 

72.00 

72.60 

75-8 

64.2 

74-4 

76 


TUBERCULOSIS    IN    MASSACHUSETTS. 


A  quotation  from  a  study  of  the  subsequent  histories  of  patients 
who  had  left  the  Sanatorium,  taken  from  the  ninth  annual  report 
of  September  30,  1905,  is  also  added. 

Subsequent  Histories  to  Date  {October  i,  1905)  of  Former  Patients  of  Both  Depart- 
ments treated  in  the  Sanatorium  Previous  to  October  i,  1904. 

The  subsequent  histories  of  former  patients  make  the  crucial  test  of  any  method 
of  treatment,  and  are  of  vital  importance. 

For  the  first  time  in  the  history  of  the  Sanatorium,  tabulations  of  the  results  of 
former  treatment  have  been  made  with  painstaking  care,  and  are  hereby  appended. 
That  they  give  us  convincing  proof  of  the  value  of  the  work  at  Rutland  in  the  past 
six  years  we  think  no  one  can  deny. 


Total  number  treated, 
Able  to  work. 
Not  able  to  work, 
No  reply  to  letter. 
No  trace. 
Dead, 


1. 179 

34 

377 

49 

56. 

2,200 


I 


Total  number  of  "  arrested" 

and  ' 

apparently  cured," 

Able  to  work. 

•      743 

Not  able  to  work. 

14 

No  reply  to  letter. 

.       139 

No  trace. 

19 

Dead, 

.         .        74' 

989 

In  reading  these  figures,  it  must  be  remembered,  moreover,  that  failure  to  receive 
replies  or  inability  to  trace  the  patient  does  not  mean  necessarily  that  the  result 
has  been  unfavorable.  In  many  of  the  earlier  cases  we  have  failed  to  receive  news 
for  months  after  the  first  inquiries  have  been  made.  Oftentimes,  too,  favorable 
accounts  have  been  received  of  former  patients  through  others.  It  is  reasonable 
to  suppose,  therefore,  that  many  of  those  from  whom  we  have  not  heard  as  yet 
are  still  alive  and  at  work. 


f 


The  estimates  for  expenses  during  the  ensuing  year  in  the  report 
of  1907  are  as  follows:  — 


Four  have  died  from  causes  other  than  tuberculosis. 


BOWDITCH. 


77 


is  made  up 


as  follows: 


For  maintenance, 

For  new  cow  barn, 

For  other  special  matters,  . 

The  estimate  for  maintenance 
Food,        .... 
Salaries  and  wages,     . 
Heat,  light  and  power, 
Repairs  and  improvements. 
Farm,       .... 
Furnishings, 
Miscellaneous  (includes  water,  medical  and  hospital  supplies,  and  all 

other  expenses),     ......... 


$185,000  00 
10,000  00 
23,375  00 

$81,470  72 

51,525  84 

15,653  07 

6,682  43 

6,1 14  14 

4,260  60 

19,293  20 
1185,000  00 


THE   MILLET    SANATORIUM  AT   EAST    BRIDGEWATER. 

This  sanatorium  was  founded  and  incorporated  under  the  laws  of 
Massachusetts  in  1900,  by  Dr.  Charles  E.  Millet  of  Brockton,  Mass., 
and  his  two  brothers,  in  memory  of  their  father.  Dr.  Asa  Millet  of 
East  Bridgewater,  who  for  many  years  was  a  physician  of  that 
locality  i-enowned  for  his  unselfish  devotion  to  others,  his  wonder- 
fully good  judgment,  and  willingness  even  in  his  advanced  years 
to  try  new  methods  of  treatment  which  appealed  to  his  common 
sense. 

His  son,  Dr.  Charles  E.  Millet,  conceived  the  idea  of  converting 
the  old  paternal  estate  into  a  sanatorium  for  tuberculous  patients, 
in  consequence  of  his  success  during  the  two  years  previous  to 
opening  the  sanatorium  in  treating  patients  in  their  homes  by 
making  them  sleep  on  open  balconies.  With  the  cordial  consent 
of  the  brothers  and  the  financial  aid  of  the  late  Mrs.  Abbie  Wild 
Ford  of  Brockton,  the  estate  was  changed  to  a  sanatorium,  which 
was  opened  in  1900.  The  buildings  are  at  an  elevation  of  only 
one  hundred  and  thirty  feet  above  sea  level,  about  twenty  miles 
from  the  sea,  and  thirty  miles  to  the  south  of  Boston. 

The  original  house  was  a  fine  old  wooden  structure,  similar  to 
many  seen  in  that  part  of  New  England,  built  from  one  hundred 


78  TUBERCULOSIS    IN    MASSACHUSETTS. 

to  one  hundred  and  fifty  years  ago.  In  the  basement  is  installed 
a  complete  hydrotherapeutic  establishment,  which  is  used  exten- 
sively in  the  treatment.  In  recent  years  additions  have  been 
made  in  the  shape  of  a  large  two-story  ward  attached  to  the  rear 
of  the  building,  and  especially  adapted  to  open-air  treatment  by 
means  of  wheeling  the  patients'  beds  on  to  adjacent  piazzas. 

About  190 1  it  became  necessary  to  build  small  "shacks"  to 
accommodate  the  increased  number  of  patients.  It  is  believed 
that  this  was  the  first  effort  to  bring  the  "shack"  into  use  in  this 
country.  These  "shacks"  are  near  the  main  building,  made  of 
wood,  twelve  by  eighteen  feet,  with  flat  roofs,  mounted  on  posts 
six  feet  from  the  ground,  and  so  arranged  as  to  allow  free  passage 
of  air  on  all  sides.  The  interiors  are  divided  into  a  bedroom  twelve 
feet  square  and  a  dressing  room  six  by  twelve  feet.  In  the  latter 
is  a  chimney  and  stove,  a  set  wash-basin  with  running  water  and 
water-closet,  a  movable  bureau  and  a  wardrobe. 

The  capacity  has  been  increased  from  ten  beds  in  1900  to  forty- 
five  in  1908.  The  Sanatorium  is  heated  by  steam  and  lighted  by 
electricity.  There  are  separate  buildings  for  nurses  and  servants. 
A  private  dairy  farm  of  tested  cows  is  a  valuable  adjunct  to  the 
institution,  and  the  sewerage  system  has  been  perfected  at  heavy 
cost.     The  water  supply  is  excellent  and  abundant. 

The  method  of  treatment  is  such  as  is  used  in  all  similar  institu- 
tions, with  the  inevitable  differences  of  detail  that  must  exist  in 
different  institutions.  Special  stress  is  laid  upon  hydro-therapy 
by  Dr.  Millet,  who  also  advocates  the  use  of  as  little  medicine  as 
possible.  The  Matron  is  a  graduate  nurse,  and  her  assistants  are 
members  of  the  Training  School  in  hydro-therapy,  massage,  prac- 
tical and  tuberculosis  nursing,  connected  with  the  Sanatorium. 
Dr.  Millet  is  the  Physician-in-Charge,  and  makes  daily  visits  to  the 
Sanatorium.  The  institution  is  not  a  charitable  one,  although 
especially  moderate  charges  are  made  to  people  of  limited  means. 


1 


I 


BOWDITCH.  79 

Patients  with  incipient  or  moderately  advanced  disease  are  re- 
ceived; but  it  is  not  intended  for  far-advanced  and  hopeless  cases. 

The  charges  vary  from  |i  5  to  I35  a  week,  according  to  size  and 
location  of  the  room  or  "shack."  "Shacks"  are  from  I25  to  I35 
a  week,  and  rooms  from  $15  to  $35.  In  the  two  wards,  one  for 
men  and  one  for  women,  with  five  beds  each,  the  price  is  |io  a 
week.  This  reduction  in  price  is  allowed  in  worthy  cases  after 
fullest  investigation.  The  institution  is  not  endowed.  The  cost 
per  patient  is,  on  an  average,  $15  per  week. 

Results,  as  stated  by  Dr.  Millet,  are:  "About  33^  per  cent,  of 
'cures,'  many  advanced  cases  having  been  admitted." 

OTHER    PRIVATE    INSTITUTIONS     IN     MASSACHUSETTS    FOR 
THE   TREATMENT  OF   CONSUMPTIVES. 

The  above-mentioned  sanatoria  are  the  largest  in  the  State;  but 
there  are  several  small  establishments,  notably  in  the  town  of 
Rutland^  under  the  charge  of  Dr.  David  P.  Butler  and  Dr.  George 
E.  Derrick,  who  have  had  much  experience  in  the  treatment  of 
tubercular  disease.  These  estabHshments  for  the  most  part  par- 
take of  the  nature  of  boarding-houses.  In  some  cases  they  are 
cared  for  by  former  patients  of  the  Rutland  Sanatorium,  but  are 
under  the  supervision  of  the  above-mentioned  physicians,  who 
make  weekly  visits,  the  cost  of  which  is  included  in  the  price  of 
board.  They  help  to  fill  a  great  need  in  our  communities,  for  the 
care  of  the  more  advanced  types  of  the  disease.  Numerous  board- 
ing-houses which  receive  cases  refused  by  the  State  Sanatorium 
exist  in  the  town  of  Rutland;  but  they  have  no  official  connection 
with  any  physician  or  with  the  Sanatorium. 

An  excellent  small  sanatorium  for  well-to-do  patients  was  estab- 
lished at  "Springside,"  Pittsfield,  Mass.,  about  two  years  ago,  by 
Miss  Mary  E.  Sullivan,  who  for  eight  years  was  head  nurse  in  the 
men's  ward  at  the  State  Sanatorium.     A  special  staff  of  the  best- 


80  TUBERCULOSIS    IN    MASSACHUSETTS. 

known  physicians  of  Pittsfield  is  connected  with  this  establish- 
ment, but  their  services  when  wanted  are  not  included  in  the  price 
of  board. 

Of  the  great  need  of  sanatoria,  in  the  strict  sense  of  the  term, 
there  can  be  no  doubt  in  the  minds  of  those  who  look  carefully  into 
the  subject.  The  experience  of  those  in  charge  of  the  Sharon 
Sanatorium  alone  would  prove  this.  The  number  of  applications 
there  far  exceeds  the  capacity  of  the  institution,  and  many  cases 
who  would  be  greatly  benefited  by  treatment  are  turned  away 
from  lack  of  room. 

At  the  same  time,  the  limitations  of  sanatorium  treatment 
must  be  kept  in  mind.  Those  who  have  had  the  greatest  ex- 
perience know  that  it  is  only  one  of  many  methods  to  be  em- 
ployed in  the  attempt  to  check  the  enormous  mortality  from 
tuberculosis.  Hospitals  for  the  far-advanced  cases,  dispensaries, 
day  and  night  camps,  instruction  and  care  in  the  homes,  in 
fact,  every  method  known  to  science  must  be  brought  to  bear, 
and  only  by  cordial  and  vigorous  co-operation  among  the  com- 
ponent parts  can  we  expect  to  accomplish  the  desired  result. 


PAGE.  8l 


CHAPTER    VII. 

TUBERCULOSIS    IN     THE    STATE    INSTITUTIONS    FOR     THE 

INSANE. 

Charles  W.  Page,  M.D. 

It  is  well  known  that  mortality  from  pulmonary  tuberculosis 
has  been  high  in  most  hospitals  for  the  insane,  and  excessively 
so  in  some.  But  obvious  causes  contribute  to  such  results.  All 
the  older  institutions  for  the  insane  have  for  years  been  main- 
taining within  their  walls  cases  of  open  tuberculosis,  which,  in 
connection  with  inefficient  methods  of  disinfection,  have  provided 
abundant  seed  for  the  propagation  of  this  disease.  Then  the 
cases  committed  to  insane  hospitals  are,  as  a  rule,  persons  in 
whom  the  mental  disorder  indicates  defective  physical  condi- 
tions,—  physiological,  nutritional  or  organic  instability;  and 
one  defect  of  this  order  may  readily  lead  to  other  debilities,  estab- 
lishing in  the  end  a  condition  of  the  lung  tissue  which  favors 
tuberculous  infection.  Too  often  such  predisposed  individuals 
are  crowded  into  wards  inadequately  supplied  with  sunlight  and 
improperly  ventilated. 

Most  insane  victims  of  pulmonary  tuberculosis  in  hospitals 
for  the  insane  represent  the  demented  classes  that  are  naturally 
inactive  and  which  are  required  to  exercise  but  little,  especially 
in  the  open  air.  Many  of  them  are  careless  and  untidy  in  their 
habits,  thus  greatly  increasing  their  chances  for  infection.  Be- 
sides, it  is  difficult  to  detect  the  incipient  and  curable  stages  of 
tuberculosis  in  such  patients.  Reflex  irritation,  cough,  etc., 
are  often  absent.  They  seldom  complain  of  pain  or  illness  of 
any  sort,  and  when  suspicion  of  pulmonary  disease  leads  to  a 
physical  examination,  they  rarely  co-operate  with  the  examiner. 


82  TUBERCULOSIS   IN    MASSACHUSETTS. 

and  thus  baffle  painstaking  efforts  to  determine  the  existence 
or  non-existence  of  early  symptoms  of  phthisis. 

However  adequate  may  be  the  explanation  of  the  high  death- 
rate  from  tuberculosis  in  hospitals  for  the  insane,  a  comparison 
of  such  mortality  rates,  as  they  have  occurred  in  various  hos- 
pitals, will  suggest  the  reflection  that  some  of  the  agencies  which 
favor  the  virulence  and  spread  of  this  disease  are  not  everywhere 
equally  active,  and  the  logical  conclusion  that  such  agencies 
are  generally  susceptible  to  suppression  or  modification.  Sta- 
tistics on  this  matter  vary  so  widely  from  year  to  year,  even  in 
a  single  hospital,  that  a  safer  judgment  will  follow  when  con- 
ditions covering  a  series  of  years  are  employed  as  a  basis  for  such 
comparison.  Consequently,  a  tabulated  statement  is  appended, 
based  upon  five-year  periods.  To  this  table  there  are  affixed  the 
results  for  the  last  hospital  year.  The  remarkable  showing  of 
the  table  is  the  reduced  percentage  of  the  mortality  due  to 
tuberculosis  which  has  taken  place  in  recent  years. 

The  Taunton  Insane  Hospital,  the  second  oldest  Massachu- 
setts state  hospital,  reported  for  one  year  eighty-three  deaths, 
of  which  number  twenty-eight,  or  33  per  cent.,  were  due  to  tuber- 
culosis. Last  year  the  same  hospital  reported  one  hundred  and 
twenty-eight  deaths,  of  which  number  five,  or  only  4  per  cent., 
were  due  to  tuberculosis.  The  interval  of  time  between  the  above 
quoted  reports  was  just  fifty  years.  It  is  possible  that  condi- 
tions were  exceptional,  and  in  opposite  directions  as  regards 
those  leading  to  tuberculous  mortality,  in  each  of  the  years  con- 
trasted; yet  little  if  any  satisfactory  data  can  now  be  obtained, 
especially  of  the  earlier  experience,  that  will  account  for  the 
different  results  that  now  appear  so  remarkable.'  Fortunately, 
efforts  to  do  so  are  less  imperative  since  the  later  report  is  so 
much  the  more  satisfactory.     The  improved  results  at  Taunton, 

I  This  hospital  liad  been  open  but  a  few  years,  and  was  at  first  partly  filled  with  chronic  cases  from 
the  Worcester  hospitals  and  almshouses. 


PAGE.  83 

as  illustrated  by  the  above  comparison,  reflect  in  a  great  measure, 
no  doubt,  the  largely  reduced  mortality  from  tuberculosis  which 
has  come  about  in  the  State  at  large  in  the  past  fifty  years.  Then, 
in  the  same  period,  the  science  of  hospital  disinfection  has  greatly 
developed.  Furthermore,  at  Taunton  the  old  ward  buildings 
have  been  in  a  considerable  measure  replaced  by  modern  struc- 
tures, insuring  more  sunlight,  better  ventilation,  etc.  Taunton, 
while  providing  no  special  wards  for  incipient  cases,  has,  in  com- 
mon with  all  the  state  hospitals,  segregated,  more  or  less  com- 
pletely, cases  of  open  tuberculosis. 

Conclusions  drawn  from  the  Taunton  reports,  as  instanced, 
may  be  comforting,  but  they  do  not  apply  to  the  broader  facts 
with  regard  to  tuberculosis  as  it  still  affects  all  the  inmates  of  the 
several  state  institutions  for  the  insane. 

The  Worcester  Hospital  for  the  Insane,  established  twenty 
years  earlier  than  the  Taunton  hospital,  never  reported  quite  so 
high  a  tuberculosis  mortality  as  did  Taunton  the  first  ten  years 
of  its  operations.  The  year  that  Taunton  reported  33  per  cent, 
of  the  total  mortality  as  due  to  tuberculosis,  Worcester  reported 
1 1. 2  per  cent.  But  ten  years  later,  in  1863,  the  death-rate  at 
Worcester  due  to  tuberculosis  was  30  per  cent,  of  the  total  death- 
rate,  while  that  at  Taunton  was  reduced  to  23.  i  per  cent. 

After  the  Worcester  Insane  Hospital  had  occupied  its  original 
buildings  about  fifty  years,  these  were  vacated  in  1878  for  a  new 
structure  removed  from  the  crowded  city.  Prior  to  this  removal, 
the  tuberculosis  percentage  of  mortality  for  a  five-year  period 
had  fallen  to  5.9  per  cent.  Contrary  to  ordinary  expectation, 
this  ratio  increased  to  12.5  per  cent,  for  the  first  five-year  tabu- 
lated period  after  the  new  buildings  were  occupied.  While  in- 
dependent buildings  for  tuberculous  patients  have  not  been 
provided  there,  separate  and  special  wards  are  utilized  for  the 
treatment  of  such  cases. 


84  TUBERCULOSIS    IN    MASSACHUSETTS. 

The  Northampton  State  Hospital  had  a  high  percentage  of 
tuberculosis  mortality  from  i860  until  after  1880,  but  since  then 
great  improvement  in  this  respect  has  been  observed.  No  special 
wards  for  the  treatment  of  tuberculosis  have  been  provided  at 
Northampton,  but  efficient  precautions  against  the  progress  of 
this  scourge  must  have  been  taken. 

The  Danvers  Insane  Hospital  has  kept  the  death-rate  from 
tuberculosis  within  the  general  average  rate  for  the  whole  group 
of  Massachusetts  hospitals  for  the  insane  until  the  past  year.  Il 
For  the  last  eight  years  special  efforts  to  limit  the  ravages  of 
tuberculosis  have  been  made.  For  a  number  of  years  tents  on 
the  lawn  were  occupied  through  as  much  of  the  year  as  the  weather 
permitted.  Subsequently  there  were  erected  two  permanent 
one-story  wooden  buildings,  one  for  men  and  one  for  women, 
each  sufficiently  large  to  accommodate  twenty  patients.  The 
men's  ward  has  been  occupied  eighteen  months;  the  women's 
ward  about  three  months. 

Pulmonary  tuberculosis  has  caused  about  the  same  proportion 
of  deaths  at  the  Westborough  Insane  Hospital  as  it  has  at  Dan- 
vers; the  tabulated  percentages  of  the  two  institutions  vary  but 
slightly.  It  is  fair  to  infer,  then,  that  about  the  same  conditions 
prevail  at  both  institutions,  and  that  the  same  explanations  will 
apply  in  both  cases.  At  Westborough  shacks  for  the  open-air 
treatment  of  tuberculosis  have  been  in  use  for  several  years, 
and  recently  a  special  sanatorium  ward  for  about  twenty  such 
cases  has  been  erected. 

Besides  the  five  state  hospitals  for  the  insane  authorized  to  re- 
ceive acute  cases  of  insanity,  Massachusetts  has  several  special 
institutions  designed  to  care  only  for  such  chronic  cases  as  are 
transferred  from  the  insane  hospitals.  Naturally  many  such 
chronic  cases  fall  victims  to  tuberculosis  in  spite  of  intelligent 
management.     Entering  an  asylum  with  lowered  vitality  incident 


( 


bo 

a 


PAGE.  85 

to  the  mental  disease,  and  augmented  by  prolonged  hospital  resi- 
dence, where  necessary  asylum  economies  are  not  calculated  to 
fortify  the  individual  against  infectious  agencies,  it  naturally  fol- 
lows that  a  large  percentage  of  such  patients  succumb  to  the 
tubercle  bacillus,  a  germ  which  appears  to  be  first  in  the  list  of 
those  causing  terminal  infections,  and  adapted  to  overcome  animal 
beings  that  have  suffered  reductions  in  the  vital  powers  of  resist- 
ance. 

The  Worcester  Insane  Asylum  began  operations  in  the  old  build- 
ings vacated  by  the  Hospital.  Into  such  wards  it  had  to  receive 
the  culled-out  chronic  cases  from  the  state  hospitals.  It  would 
seem  as  though  these  conditions  favored  a  high  death-rate  from 
tuberculosis  in  this  as  well  as  the  other  asylums.  Under  the  cir- 
cumstances, a  percentage  of  27.8  is  not  surprising,  especially  since 
it  is  noted  that  the  percentage  indicates  simply  the  ratio  of  tuber- 
culosis to  other  fatal  diseases,  and  the  further  important  fact  that 
the  percentage  of  all  deaths  based  upon  the  daily  average  popula- 
tion of  the  asylum  was  only  about  one-half  as  high  last  year  in  the 
Worcester  Asylum  as  it  was  in  the  state  insane  hospitals. 

For  a  number  of  years  the  Worcester  Asylum  has  been  develop- 
ing a  colony  in  North  Grafton,  where  better  facilities  for  special 
methods  of  treating  tuberculosis  can  be  provided.  During  the 
past  season  one  man  with  pulmonary  tuberculosis  has  been  living 
in  a  tent  pitched  in  the  woods;  this  case  has  improved  greatly, 
gaining  much  in  weight. 

At  the  Medfield  Asylum  there  are  about  fifteen  hundred  patients. 
They  occupy  modern  buildings,  but  in  most  respects  they  are  to  be 
classed  with  the  inmates  of  Worcester  and  the  other  asylums. 
Those  manifestly  subject  to  tuberculosis  are  segregated  in  special 
buildings,  and  approved  methods  of  treatment  are  employed. 
The  percentage  of  19.5  is  no  doubt  low  for  such  cases  as  are 
segregated  at  Medfield. 


86  TUBERCULOSIS    IN    MASSACHUSETTS. 

At  Tewksbury,  where  there  is  a  department  for  the  chronic 
insane,  a  percentage  of  18.6,  representing  the  tuberculosis  mor- 
tality, could  not  be  obtained  were  not  special  wards  for  such 
cases  provided  and  special  treatment  given.  Two  hospital  build- 
ings specially  constructed  for  the  care  of  such  cases  have  been 
erected;  one  hundred  men  and  forty  women  can  be  accommodated 
in  these  buildings.  Besides,  there  are  four  shacks,  each  of  which 
will  accommodate  twenty  patients.  Of  course  the  insane  con- 
stitute but  a  small  proportion  of  the  tuberculous  cases  thus 
managed  at  Tewksbury. 

At  the  State  Farm  there  are  five  hundred  and  forty  of  the 
criminal  insane.  Last  year  there  were  only  twenty-three  deaths 
from  all  causes;  thirteen  of  these  died  of  tuberculosis,  thus  giving 
a  percentage  of  56.  5,  which  cannot  be  considered  excessive  under 
the  circumstances  that  must  prevail  in  such  institutions. 

The  Gardner  Colony  has  a  limited  number  of  patients,  mostly 
men,  and  only  a  few  deaths  occurred  there  last  year;  but  as  more 
than  one  in  four  of  those  who  died  had  tuberculosis,  the  percentage 
is  26.6. 

The  insane  department  at  Foxborough  has  been  receiving 
patients  but  a  short  time,  and  previous  to  the  present  hospital 
year  had  had  no  deaths  due  to  tuberculosis. 

For  the  past  year  14.6  represents  the  percentage  of  deaths  from 
pulmonary  tuberculosis,  when  all  the  inmates  of  Massachusetts 
state  institutions,  hospitals  and  asylums  are  considered  together. 
Taking  the  combined  population  in  the  five  state  hospitals,  the 
percentage  is  10.6. 

In  the  year  1900  Dr.  A.  H.  Harrington  collected  statistics  on 
the  subject  from  hospitals  for  the  insane  throughout  the  United 
States.  In  his  published  report '  he  does  not  single  out  the 
Massachusetts  hospitals,  but  does  group  those  in  New  England, 

•  Proceedings  American  Medico-Psychological  Association,  1900,  7,  202. 


PAGE.  87 

and  shows  that  1 1 .9  per  cent,  was  the  average  of  tubercular  mor- 
taHty  in  the  whole  group.  Compared  with  that  statement,  the 
statement  is  warranted  that  Massachusetts  insane  hospitals  now 
have  a  better  average  than  that  for  all  New  England.  Dr.  Har- 
rington also  found  that  the  percentage  of  the  total  death-rate  due 
to  tuberculosis  in  the  New  England  hospitals,  when  compared 
with  the  records  of  other  groups  of  hospitals  representing  condi- 
tions in  different  sections  of  the  country,  was  the  lowest  of  all. 
In  fact,  the  death-rate  increased  in  the  directions  of  south  and 
southwest  as  follows:  New  England  States,  11. 9  per  cent.;  Mid- 
dle States,  13.8  per  cent.;  Western  and  Southwestern  States,  i6.8 
per  cent.;  Southern  States,  20.1  per  cent. 

In  order  to  understand  to  what  extent  Massachusetts  hospitals 
are  responsible  for  maintaining  conditions  which  favor  the  spread 
of  tuberculosis,  the  hospital  residence  of  those  who  died  from  the 
disease  the  past  hospital  year  is  herewith  tabulated:  — 


88 


TUBERCULOSIS    IN    MASSACHUSETTS. 


•<4. 

a; 


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h 
0 

H 

H 

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1             M           N           fO         «n          N           C-        00 

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Hospital. 

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Hospital. 

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,               „             -             -             -            ^           ^           - 

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Northampton 

State 

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Taunton 

Insane 

Hospital. 

H 

1            1             1            1             1            M         -          - 

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^' 

1            1             1            1            1            -          -          - 

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Worcester 

Insani; 
Hospital. 

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s 

1       1       1       1       1       1       ■»     ■« 

o> 

FOR  THE    HOSPITAL   YKAR.  1906-07. 

Under  one  month, 

From  3  to    6  months, 

From  I  to    2  years,      ........ 

From  s  to  lo  years 

1 

I 


PAGE. 


89 


Table  showing  the  Percentage  of  all  Deaths  due  to  Tuberculosis  in  the  Massachusetts 

Institutions  for  the  Insane. 


~ 

V             OJ         1     i      ■    1    u 

V 

c 

ffS 

(Jn 

c 

C 

B 

V 

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s 

s   . 

c 

0 

2 

c 

•"• 

s 

c 

c 

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C 

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3 

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11 

3 
^■5. 

5  0 

s  i 

2! 

0 
0 

2S 

0  0 

oK 

C   0 

~  0 

>  0 

5K 

s^ 

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0,   C 

c 

^ 

H 

^s 

Q 

;s 

IS 

S 

CA         w 

0 

fa 

Based    upon   deaths 

in   5 -year 

periods : — 

1840-45, 

9.2 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

1850-53, 

13-8 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

1S60-65, 

24.8 

25-5 

33-9 

- 

- 

- 

- 

- 

- 

- 

- 

1870-73. 

5.8 

5-6 

28.2 

- 

- 

- 

- 

- 

- 

- 

- 

18S0-85, 

12.5 

8.6 

22.0 

10.3 

- 

- 

- 

- 

- 

- 

- 

1890-^3. 

10.7 

10.7 

I2.0 

II.  I 

10.0 

- 

- 

- 

- 

- 

- 

iqoo-03. 

12-3 

10. 1 

7-7 

9-3 

9-7 

21.4 

13. 1 

14-9 

23-5 

- 

- 

For  the  hospit 

al  ye 

ir  igc 

)6-07 

8.6 

4.0 

7.0 

'5-3 

15.0 

27.8 

19.5 

18.6 

56-5 

26.6 

- 

Of  the  seventy-three  deaths  reported  from  the  five  insane  hos- 
pitals, fourteen  died  within  one  year  from  the  date  of  their  com- 
mitment. In  our  northern  dimate,  few  cases  of  tuberculosis 
terminate  in  death  within  a  period  of  twelve  months  from  incep- 
tion, hence  it  is  fair  to  infer  that  these  persons  contracted  the 
disease  prior  to  their  hospital  residence.  But  three-fourths  of  the 
whole  number  had  spent  two  years  or  longer  within  the  hospital 
walls.  A  majority  of  these  no  doubt  died  from  hospital  tubercu- 
losis. It  seems  unnecessary  to  tabulate  the  hospital  residence  of 
eighty-five  others  who  died  in  the  various  state  asylums.  Each 
patient  had  experienced  a  more  or  less  prolonged  hospital  residence 
before  being  transferred  to  asylum  care.  Such  individuals  can 
reasonably  expect  a  change  of  environment  only  by  death,  and  it 
seems  to  be  a  law  of  nature  that  terminal  infections  shall  ultimately 
arrest  a  majority  of  human  lives.  In  a  series  of  one  hundred 
autopsies  performed  in  the  Danvers  Hospital  Laboratory,  it  was 
found  that  terminal    infections  had  invaded  the  heart's  blood 


90  TUBERCULOSIS   IN   MASSACHUSETTS. 

in  sixty-four  cases,  and  the  cerebro-spinal  fluid  in  seventy-five 
cases. 

The  high  tuberculosis  mortality  reported  from  Danvers  Insane 
Hospital  during  the  past  year  calls  for  further  analysis.  While 
the  special  wards  for  tuberculous  cases  were  under  construction, 
methods  calculated  to  prevent  or  arrest  this  disease  were  less 
actively  enforced  than  at  present,  and  the  use  of  tents  was  aban- 
doned. Then  the  state  care  act,  through  the  pressure  of  local 
economy  in  town  and  city  management,  operates  to  increase  the 
commitment  of  some  patients  already  infected  with  tuberculosis. 
As  the  public  conception  of  the  old  forbidding  lunatic  asylums  has 
been  gradually  brought  into  harmony  with  the  new  christening, 

—  state  hospitals,  —  candidates  for  the  wards,  as  well  as  their 
friends,  more  readily  assent  to  the  suggestion  that  they  resort  to 
institutions  of  this  class  when  health  is  broken.  Patients  have 
been  received  at  Danvers  when  the  sole  evidence  of  insanity  was 
the  deUrium  incident  to  the  terminal  stages  of  tuberculosis. 

Of  those  who  died  at  Danvers  last  year,  seven  had  been  in  the 
hospital  less  than  twelve  months,  and  six  of  these  died  within  six 
months  of  their  entrance.  Again,  the  misleading  possibihties  of 
statistics  when  employed  in  connection  with  limited  time  or 
restricted  circumstances  should  be  borne  in  mind.  This  sugges- 
tion may  be  emphasized  by  noting  that  while  for  the  hospital  year 
ending  November  30,  1907,  Danvers  had  twenty-six  deaths  from 
tuberculosis,  —  a  mortality  per  cent,  of  15.3,  — for  the  first  half 
of  the  succeeding  or  present  year,  /.  e.,  the  six  months  ending  May 
30,  1908,  but  three  cases  of  tuberculosis  have  died  in  the  hospital, 

—  a  mortality  per  cent,  of  only  2.5.  The  shack,  or  special  ward 
for  male  patients  with  tuberculosis,  has  been  in  use  eighteen 
months  at  Danvers,  but  this  fact  does  not  explain  the  reduced 
mortality  from  tuberculosis,  although  favorable  results  are  being 
accomplished  through  the  aid  of  this  ward.     Already  it  has  re- 


DANVERS    INSANE    HOSPITAL    AT    HATHORNE.  —Special    Ward 
Building    for    Tuberculous    Patients,   showing    Veranda. 


PAGE.  91 

ceived  thirty-four  men  by  transfer  from  the  wards  of  the  main 
hospital.  Of  this  number,  nine  have  died,  seven  of  the  nine  having 
shown  physical  signs  of  tuberculosis  when  admitted  to  the  hos- 
pital. Of  the  thirty-four  so  far  treated,  sixteen  are  still  inmates; 
thirteen  of  the  number  have  gained  in  weight,  —  an  average  of 
twenty-one  and  one-half  pounds;  the  other  three  have  lost, — 
an  average  of  six  and  one-third  pounds.  As  a  rule,  open  cases 
of  tuberculosis  are  still  cared  for  in  certain  parts  of  the  main 
hospital,  and  a  few  have  been  too  unreliable  for  residence  in  the 
special  wards. 

In  order  to  give  tuberculous  inmates  the  benefit  of  special 
treatment  in  the  incipient  stages  of  the  disease,  a  routine  tempera- 
ture examination,  four  times  daily,  of  all  chronic  demented  pa- 
tients, and  others  as  circumstances  suggest,  is  repeated  several 
times  each  year.  A  continuous  rise  in  temperature  or  a  marked 
loss  in  bodily  weight  suffices  for  an  order  of  transfer  to  the  tuber- 
culosis ward,  unless  the  patient  is  too  irritable  or  excitable  for 
continuous  residence  there. 

The  continued  use  of  the  tuberculin  test  in  a  large  series  of  cases 
covering  a  period  of  several  years  gave  such  unsatisfactory  results 
in  differentiating  incipient  cases  that  it  has  been  discarded  at  the 
Danvers  Insane  Hospital.  Although  tuberculin  has  failed  to 
identify  early  tubercular  lung  disease,  faith  in  its  reliability,  when 
properly  used,  to  demonstrate  the  presence  without  regard  to 
location  of  infected  foci,  is  not  diminished.  The  ophthalmic  reac- 
tion has  also  been  found  to  be  unreliable  in  detecting  incipient 
tuberculosis,  and  has  been  discarded. 

In  addition  to  the  many  phases  of  the  tubercular  problems  which 
arise  in  connection  with  the  insane,  the  state  hospitals  have  to 
contend  with  bovine  tuberculosis,  as  each  hospital  has  a  farm  with 
a  herd  of  milch  cows.  For  the  past  twenty  years  this  disease  has 
been  so  common  in  the  hospital  dairy  stock  as  to  occasion  serious 


Q2  TUBERCULOSIS    IN    MASSACHUSETTS.  _ 

concern.  For  a  time  it  was  feared  that  the  milk  from  the  diseased 
cows  might  be  communicating  tuberculosis  to  the  patients.  Later, 
when  new  theories  modified  such  views,  there  still  remained  the 
great  annual  financial  loss  to  the  State  from  the  steady  inroads 
of  this  disease.  The  experience  at  Danvers  probably  duplicates 
that  at  all  the  other  state  hospitals.  In  1888,  when  the  first 
official  examination  of  horned  cattle  belonging  to  the  hospital  was 
made,  out  of  the  sixty-one  animals,  twelve  were  condemned  as 
worthless,  twenty-five  were  classed  as  probably  diseased,  and 
twenty-four  only  were  given  a  clean  bill  of  health.  Since  that 
time  animals  manifesting  this  disease  have  been  discarded  and 
fresh  stock  brought  in.  Measures  to  insure  the  disinfection  of  the 
stable  and  to  improve  the  sanitary  conditions  of  the  barn  have 
been  enforced,  and  yet  no  abatement  of  the  infection  has  been 
evident.  From  time  to  time  the  tuberculin  test  has  been  em- 
ployed. In  the  year  1900,  64  per  cent,  of  the  whole  herd  reacted. 
The  Bon  system  of  removing  diseased  animals  from  the  barns  has 
been  steadily  practised  and  thorough  disinfection  carried  out,  but 
without  appreciable  effect  in  diminishing  the  prevalence  of  the 
disease.  In  April,  1906,  the  Danvers  Hospital  Trustees  decided 
to  adopt  von  Behring's  method  of  immunizing  dairy  stock  to  pre- 
vent infection  from  tubercle  bacilli.  This  practice  consists  in 
giving  two  injections,  three  months  apart,  of  a  special  quality  of 
human  tubercle  bacilli  into  the  blood  current  through  the  jugular 
vein.  The  Northampton  State  Hospital  began  to  treat  young 
animals  in  this  manner  at  about  the  same  date,  and  thirty  calves 
had  been  thus  immunized  at  the  close  of  the  last  hospital  year. 

To  date,  Danvers  has  seventy-eight  on  the  list  of  immunized 
animals.     Time  alone  can  satisfactorily  demonstrate  the  value  of 
this  system  of  fighting  bovine  tuberculosis,  but  in  Europe  von    i 
Behring's  Bovovaccine  has  been  in  extensive  use  twice  as  long  as 
in  the  United  States,  and  all  reports  seem  to  support  the  original 


PAGE.  93 

claims  that  by  this  treatment  horned  animals  are  rendered  com- 
paratively immune.  No  injurious  results  from  the  operation  have 
been  observed  at  Danvers. 

The  tuberculin  tests  so  far  made  on  immunized  stock  have  been 
generally  negative,  but  it  is  recognized  that  the  vaccination  sensi- 
tizes the  animals  for  a  period  of  at  least  seven  to  twelve  months. 
(Von  Behring  and  Romer.) 

How  much  credit  for  such  results  as  have  been  obtained  at  the 
Danvers  Insane  Hospital  should  be  attributed  to  the  immunizing 
process  may  remain  a  question,  for  a  time  at  least;  but  such 
favorable  evidence,  constantly  accumulating,  stimulates  courage 
to  believe  that  a  certain  means  for  checking  bovine  tuberculosis 
has  been  discovered.  And  if  bovovaccination  proves  successful, 
it  is  not  too  much  to  expect  that  there  will  be  at  our  command, 
in  due  time,  equally  efficient  methods  for  checking  human  tuber- 
culosis. 


94  TUBERCULOSIS    IN    MASSACHUSETTS. 


CHAPTER   Vin. 

TUBERCULOSIS  IN  THE  PRISONS  OF  MASSACHUSETTS. 
Joseph  I.  McLaughlin,  M,D. 

The  Massachusetts  Board  of  Prison  Commissioners  have  the 
control  and  management  of  the  three  large  prisons  of  the  State, 
the  Women's  Reformatory  at  Sherborn,  the  Reformatory  at  Con- 
cord for  young  male  adults  and  the  State  Prison  at  Charlestown. 
In  addition,  they  have  a  general  supervision  over  the  twenty-one 
jails  or  houses  of  correction  or  both  in  the  various  counties.  As 
the  latter,  with  two  or  three  exceptions,  have  no  appointed  hos- 
pitals and  issue  no  tabulated  report  of  the  sick  inmates,  it  is 
possible  to  consider  in  this  study  only  the  measures  in  use  for  the 
care,  and  more  particularly  the  prevention,  of  tuberculosis  in  the 
larger  institutions  named  above.  The  two  reformatories,  being 
of  more  recent  construction  and  situated  in  the  open  country, 
with  a  wide  area  of  land  adjoining  which  is  owned  by  the  State,  ^| 
present  far  less  difficulty  in  carrying  out  appropriate  measures  for 
the  control  of  tuberculosis  than  does  the  State  Prison,  the  oldest 
of  the  three.  It  is  intended,  then,  to  speak  but  briefly  of  the 
former  institutions  and  more  at  length  of  conditions  at  the  State 
Prison. 

At  the  Women's  Reformatory  in  Sherborn  tuberculosis  has  not 
gained  a  very  strong  foothold,  and  this  can  be  attributed  to  a  great 
extent  to  the  measures  employed  at  this  excellent  institution  to 
maintain  the  general  health  of  the  prison,  such  as  gymnastic  ex- 
ercises, a  liberal  amount  of  work  in  the  open  air,  light  gardening 
and  farming,  etc.  From  the  product  of  the  fields  the  table  of  the 
inmates  is  constantly  supplied  with  a  generous  quantity  of  fresh 
fruit  and  vegetables.     The  good  results  following  such  manage- 


Mclaughlin.  95 

merit  are  shown  in  the  yearly  medical  reports.  During  the  last 
twelve  years  only  two  deaths  occurred  from  tuberculosis,  with  an 
average  population  of  nearly  two  hundred  and  fifty. 

The  Reformatory  at  Concord,  established  in  1884,  for  the  im- 
prisonment of  young  male  adults  with  sentences  ranging  from 
twelve  months  to  five  years,  has  a  very  low  general  death-rate, 
with  tuberculosis  as  the  principal  cause  of  death,  as  seen  from  the 
following:  from  1855  to  1907  inclusive,  the  average  yearly  popu- 
lation was  eight  hundred  and  thirty-seven.  The  average  yearly 
number  of  deaths  from  all  causes  was  three,  of  which  one  was  due 
to  tuberculosis. 

Tuberculosis  is  a  community  disease,  and  develops  and  spreads 
most  readily  in  places  where  the  accepted  rules  of  sanitation  are 
not  enforced.  Cleanliness,  proper  ventilation,  good  food  and 
exercise  are  of  the  greatest  importance  in  protecting  the  individual 
from  infection.  In  a  state  prison,  however,  it  is  most  difficult  to 
observe  these  requirements,  inasmuch  as  the  community  is  largely 
composed  of  physical  and  moral  degenerates,  and  society  demands 
that  it  shall  be  surrounded  by  such  safeguards  as  shall  make 
escape  impossible. 

It  is  not  to  be  wondered  at  that  in  the  Massachusetts  State 
Prison  the  physician  in  former  years  waged  a  losing  fight  against 
tuberculosis,  when  we  read  of  the  conditions  existing  at  that  time. 
The  prisoner  spent  the  greater  part  of  his  time  in  a  cell  three  and 
one-half  feet  wide,  seven  feet  long  and  seven  feet  high,  having  a 
solid  iron  door  with  a  small  grating  at  the  top,  which  served,  or 
was  supposed  to  serve,  the  purpose  of  admitting  a  sufficient 
quantity  of  light  and  air.  In  the  lower  part  of  the  encircling 
prison  wall  there  were  no  windows,  and  even  in  the  hospital  with 
its  fourteen  cells  there  were  but  three  small  windows.  This  criti- 
cism does  not  apply,  however,  to  cells  built  in  later  years.  For 
instance,  some  are  nine  and  one-half  feet  long  by  six  feet  wide, 


96  TUBERCULOSIS    IN    MASSACHUSETTS. 

with  the  windows  in  the  outer  wall  extending  almost  from  floor 
to  roof,  while  others  are  sixteen  feet  long,  twelve  feet  high  and 
eight  feet  wide,  all  the  cells  in  addition  being  supplied  with  a 
suitable  means  of  ventilation.  The  larger  cells  have  two  windows 
at  the  top  opening  directly  into  the  outer  air. 

At  the  present  time  the  physician  sees  each  prisoner  when  com- 
mitted, and  if  there  is  a  suspicion  of  his  having  a  communicable 
disease  he  is  kept  under  special  observation  until  all  doubt  is 
removed.  All  others  are  assigned  work,  commensurate  with  their 
abilities,  by  the  warden.  The  clothes  worn  during  imprisonment, 
except  in  certain  cases,  are  destroyed,  and  a  new  outfit  is  given 
them  at  the  time  of  their  discharge.  Each  prisoner's  clothing  and 
bed  clothes  are  marked  with  his  name,  which  reserves  them  for  his 
wear  only,  and  these  also  as  a  rule  are  destroyed  when  the  prisoner 
is  discharged.  In  the  case  of  a  prisoner  who  is  suspected  of  having 
a  communicable  disease,  all  danger  to  others  is  avoided  by  the 
separate  washing  and  sterilization  of  his  clothing. 

The  regular  prison  fare  is  nourishing,  generous  and  varied,  and 
consists  of  milk  with  cereals  or  meats  and  bread  and  coffee  for 
breakfast;  stews,  fish  or  meats  with  vegetables  and  bread  fo*- 
dinner;  and  bread,  coffee,  prunes  or  apple  sauce,  etc.,  for  suppe". 
Each  prisoner  is  also  given  the  privilege  of  ordering  enough  fruit 
in  season  once  a  week  to  furnish  a  daily  supply  for  the  remainder 
of  the  week.  As  an  extra  precautionary  measure,  all  food  or 
clothing  coming  from  friends  or  relatives  is  withheld  from  the 
prisoner. 

The  workshops  are  well  lighted  and  ventilated,  and  the  character 
of  the  work  is  healthful.  The  dark  punishment  cell  ("solitary  con- 
finement," so  called),  with  its  deprivation  of  light  and  the  diet 
limited  to  bread  and  water,  as  time  goes  on  is  less  frequently  called 
into  use  in  dealing  with  refractory  prisoners.  The  number  of 
punishments  of  this  nature  in  one  year  at  the  State  Prison  has  for 


jlllTiiilTE 


HOSPITAL    PRISON    FOR    CONSUMPTIVES    AT    RUTLAND. 


Mclaughlin. 


97 


a  considerable  period  exceeded  by  only  a  small  margin  the  number 
of  punishments  of  this  type  given  in  one  week  in  penal  institutions 
in  other  States.  Bodily  cleanliness  is  rigidly  enforced,  each  pris- 
oner being  compelled  to  bathe  the  whole  surface  of  the  body  at 
least  once  a  week. 

The  present  administration  having  practically  extended  over  a 
period  of  fifteen  years  with  a  view  to  comparative  results,  the 
records  of  the  two  preceding  corresponding  periods  were  looked 
up,  and  this  brief  summary  is  presented:  — 


PERIODS. 


Average 

Yearl}'  Number 

of  Prisoners. 


No.  of  Deaths 

from  All 

Causes  per  loo 

Prisoners. 


Percentage  of 

All  Deaths 

Due  to 

Tuberculosis. 


1861-75  inclusive, 
1876-90  inclusive, 
1891-05  inclusive, 


524 
638 
771 


'•74 
1.68 
0.57 


54 
49 
32 


The  average  age  at  death  from  tuberculosis  during  the  last  period 
was  twenty-eight,  exclusive  of  two  whose  ages  were  forty,  one  at 
forty-eight  and  another  at  fifty-one.  The  average  duration  of 
imprisonment  at  time  of  death  was  three  years,  exclusive  of  two 
terms  of  six  years  each,  and  two  others,  one  of  whom  was  in  prison 
sixteen  years,  the  other  twenty-four  years. 


PRISON    HOSPITAL   AT   RUTLAND. 

Although  the  statistics  of  tuberculosis  in  our  reformatories  and 
prison  compared  most  favorably  with  those  of  similar  institutions 
in  this  and  other  countries,  the  Board  of  Prison  Commissioners, 
through  its  chairman,  Mr.  Frederick  C.  Pettigrove,  keeping  in 
touch  with  the  best  thought  of  the  day,  looked  for  better  results, 
and  effected  the  passage  of  a  law  in  1905  establishing  a  hospital 
for  the  reception  of  prisoners  ill  with  tuberculosis  from  the  various 
prisons  and  jails  of  the  State.     A  site  was  selected  about  five  miles 


98  TUBERCULOSIS    IN    MASSACHUSETTS. 

from  the  State  Sanatorium  at  Rutland,  on  land  with  an  elevation 
of  about  one  thousand  feet  above  the  sea  level,  and  the  hospital 
built  thereon  received  its  first  patient  in  the  latter  part  of  Septem- 
ber, 1907.  When  a  prisoner  receives  his  court  sentence  and  is 
committed  to  a  jail  or  prison,  as  the  case  may  be,  and  is  then  found 
to  have  tuberculosis,  the  attending  physician  fills  out  a  certificate 
and  forv^ards  it  to  the  Prison  Commissioners,  who  then  order  the 
prisoner  transferred  to  the  Prison  Hospital  at  Rutland. 

This  hospital  is  built  on  the  pavilion  plan  and  consists  of  two 
large  wings,  placed  parallel,  which  run  directly  north  and  south; 
an  administration  building  joins  the  northern  ends  of  the  two  ward 
pavilions,  the  three  buildings  forming  three  sides  of  a  large  rec- 
tangular area.  This  area  on  its  fourth  side  will  be  enclosed  by  a 
stockade  wall  so  placed  on  the  slope  of  the  hill  as  to  offer  no  ob- 
struction to  the  view  or  the  warm,  pure  southern  breezes.  Keep- 
ing in  view  the  necessity  of  an  abundance  of  pure  air  and  light, 
the  buildings  are  so  arranged  that  the  patient  gets  the  full  benefit 
of  both  when  conditions  permit.  The  walls  of  the  east  dormitory 
are  made  of  corrugated  iron  on  a  wooden  frame,  the  walls  of  the 
west  dormitory  of  cast  stone,  the  administration  building  of  rubble 
stone.  The  dormitories  or  wards  are  large,  with  double  tiers  of 
windows,  suitably  grated,  extending  to  the  roof,  and  at  the  north- 
erly end  of  each,  adjoining  the  administration  building,  are  rooms 
for  the  more  advanced  or  special  cases.  Long,  open  iron-grated 
verandas  at  the  sides  and  ends  of  the  dormitories  afford  the  oppor- 
tunity for  open-air  treatment  day  and  night. 


I 


BRADFORD. 


99 


CHAPTER   IX. 

THE  TREATMENT  OF  SURGICAL  TUBERCULOSIS  IN 
MASSACHUSETTS. 

Edward  H.  Bradford,  M.D. 

In  the  publications  of  the  various  associations  engaged  in  com- 
bating tuberculosis,  as  a  rule  more  attention  is  paid  to  the  attempts 
to  check  the  pulmonary  form  than  to  the  surgical  efforts  against 
it.  This  is  to  be  explained  by  the  fact  that  public  attention  has 
been  turned  more  especially  to  the  medical  rather  than  the  surgi- 
cal features  of  tuberculosis,  and  also  because  the  surgical  type  is 
not  as  threatening  a  source  of  contagion  as  that  more  common 
form,  —  phthisis.  Bone  tuberculosis  is  in  its  most  aggressive 
form  to  be  seen  in  childhood,  and  is  usually  cared  for  in  the  family 
home.  In  adult  life  the  active  phase  of  the  disease  has  terminated, 
if  not  fatally,  in  some  form  of  crippling  deformity  which  may  im- 
pair individual  activity  but  does  not  endanger  public  health.  In 
the  severer  cases  cripples  are  objects  of  pity  and  charity  but  not 
of  medical  care,  and  are  to  be  found  either  in  the  almshouse  or  in 
private  homes,  where  they  do  not  endanger  the  health  of  the 
community. 

The  distressing  nature  of  bone  tuberculosis,  and  the  severe  in- 
fliction it  often  entails,  however,  justifies  every  effort,  surgical  as 
well  as  medical,  to  eradicate  or  check  it.  The  closest  study  of 
every  feature  and  manifestation  of  one  of  the  chief  maladies 
crippling  mankind  is  a  public  duty. 

Surgical  tuberculosis  is  a  broad  subject,  and  in  this  chapter 
attention  is  paid  chiefly  to  that  form  affecting  the  bones,  not  only 
because  it  presents  one  of  the  most  common  forms  of  surgical 
tuberculosis,  but  because  the  osseous  system  plays  so  important 


100  TUBERCULOSIS    IN    MASSACHUSETTS. 

a  part  in  human  activity  that  special  arrangements  are  often 
needed  to  meet  the  indications  of  treatment  demanded. 

The  therapeutics  of  an  infection  depend  in  a  great  measure  upon 
the  accepted  theory  of  the  nature  of  the  disease.  What  is  now 
classed  as  bone  tuberculosis  has  passed  through  various  phases 
of  medical  classification.  In  the  past  medical  generation  it  was 
still  classed  as  scrofula,  and  a  survival  of  the  old  "humoral  path- 
ology" persisted.  When  this  was  overthrown  by  the  acceptance 
of  the  theory  of  "cellular  pathology,"  bone  tuberculosis  was  at- 
tacked chiefly  as  an  affection  of  a  definite  tissue  which  demanded 
eradication.  With  the  advance  of  the  germ  theory  and  the  demon- 
stration of  the  tuberculous  nature  of  this  form  of  caries,  treatment 
was  directed  to  the  destruction  of  the  germ;  and  more  recently, 
since  the  theory  of  antitoxins  and  immunity  has  been  developed, 
the  chief  aim  has  been  to  develop  a  condition  of  the  tissues  which 
would  resist  the  invasion  of  the  specific  germs-. 

Corresponding  to  these  different  theories,  the  treatment  of  bone 
tuberculosis  has  ranged  from  the  employment  of  issues,  setons, 
the  cautery,  radical  surgical  intervention  {i.e.,  excision  and  am- 
putation), the  use  of  apparatus,  the  administration  of  drugs  and 
antitoxins,  to  the  employment  of  fresh  air  and  activity  for  the 
development  of  normal  and  healthy  metabolism. 

In  New  England,  and  especially  in  Massachusetts,  the  facilities 
for  the  surgical  treatment  of  bone  tuberculosis  were,  until  within 
the  last  fifty  years,  confined  chiefly  to  counter-irritants,  blisters, 
and  to  the  relief  of  pain  and  discomfort.  Hospitals  were  not 
equipped  for  chronic  cases;  where  patients  demanded  admission, 
it  was  for  amputation  or  the  radical  removal  of  diseased  bone. 
The  application  of  braces  was  left  largely  to  instrument  makers 
and  empirics.  Those  suffering  from  these  affections  were  aided 
chiefly  by  such  advice  and  oversight  as  counseled  good  nutrition 
and  the  administration  of  tonics.     In  this  respect  New  England 


BRADFORD.  .  lOI 

was  in  no  way  behind  other  communities.  There  was  a  general 
skepticism  both  in  the  minds  of  the  community  and  in  that  of  the 
profession  as  to  the  advisabiUty  of  any  attempts  at  treatment  for 
what  were  termed  the  "scrofulous  diseases."  At  present  leprosy 
in  Japan  is  popularly  considered  a  divinely  decreed  blight,  and  not 
within  human  power  to  control;  and,  according  to  popular  opinion 
of  the  past  generation  in  this  community,  all  attempts  to  cure 
children  with  hip  disease  and  tuberculosis  of  the  spine  were  re- 
garded as  futile  and  little  more  than  palliative.  It  was  even 
regarded  by  many  as  wrong  to  attempt  to  prolong  the  life  of 
scrofulous  children.  Later,  as  the  medical  tradition  of  scrofula 
and  the  belief  in  the  "humoral  pathology"  passed,  direct  surgical 
interference  seemed  to  offer  a  hope  of  cure  by  the  eradication  of 
the  diseased  cellular  tissue.  Excision  of  the  ends  of  the  bone  was 
commonly  attempted  at  the  hospitals  where  such  cases  were  re- 
ceived. As  rest  was  essential  in  the  painful  stages  of  tuberculosis 
of  the  larger  joints,  some  form  of  fixation  of  the  joint  was  regarded 
as  advisable;  and  patients  suffering  from  Pott's  disease  and  disease 
of  the  knee  and  ankle  were,  when  under  medical  care,  kept  in  bed. 
Avoidance  of  fresh  air  and  the  administration  of  alcohol  were 
commonly  advised.  A  few  even  at  this  period  recognized  the 
advantages  of  country  air,  but  organized  efforts  for  climatic  cure 
were  not  attempted. 

Later,  much  attention  was  paid  to  furnishing  patients  with 
mechanical  appliances  which  would  correct  deformity  or  protect 
the  limb  from  jar.  The  treatment  by  counter-irritation,  by  long 
periods  of  enforced  rest,  followed,  combined  with  radical  surgical 
intervention  where  other  measures  failed.  These  constituted  for 
many  years  the  recognized  methods  of  treatment  for  bone  tuber- 
culosis. The  pathology  of  these  affections  was  not  well  under- 
stood. Authorities  discussed  whether  scrofulous  bone  affections 
were  in  reality  tuberculous.     As  all  doubts  on  this  subject  were 


102  TUBERCULOSIS    IN    MASSACHUSETTS. 

ended  by  the  advance  of  pathological  knowledge,  the  importance 
of  some  form  of  treatment  which  would  directly  check  and  over- 
come the  tuberculous  germs  became  apparent,  and  the  efforts  to 
develop  a  healthy  condition  of  the  body,  and  in  that  way  overcome 
the  tuberculous  condition,  seemed  justified. 

HOUSE   OF   THE    GOOD    SAMARITAN. 

The  beginning  of  a  systematic  attempt  to  treat  those  afflicted 
with  bone  tuberculosis,  in  Massachusetts,  was  made  through  the 
efforts  of  a  noble  woman,  Miss  Anne  Robbins  of  Boston,  who 
devoted  not  only  her  small  fortune,  but  her  life,  to  the  establish- 
ment of  the  House  of  the  Good  Samaritan.  This  institution  was 
founded  in  1861  to  receive  patients  who  could  not  be  admitted  to 
the  Massachusetts  General  Hospital,  then  the  only  large  hospital 
in  Boston.  An  especial  ward  was  provided  for  children  with  hip 
and  spine  disease.  Dr.  Buckminster  Brown,  who  in  his  early 
youth  suffered  from  caries  of  the  spine,  and,  recovering  after  years 
of  suffering  with  a  severe  deformity,  became  a  successful  practi- 
tioner in  orthopedic  surgery,  was  placed  in  charge  of  this  ward. 
Painstaking  care  was  given  to  those  admitted  to  the  hospital, 
with  the  aid  of  such  appliances  as  were  then  in  use.  The  treatment 
was  thorough,  and  those  leaving  the  hospital  were  followed  with 
charitable  interest  for  years  by  Miss  Robbins  and  her  nurses.  The 
advantages  of  country  air  were  manifest,  and  those  patients  who 
were  able  to  be  moved  and  who  did  not  require  constant  surgical 
attendance  were  placed  in  country  homes  in  many  instances,  and 
later  a  farmhouse  in  the  suburbs  of  Boston  was  utilized  as  a  con- 
valescent home  for  the  institution. 

A  tribute  of  respect  and  admiration  is  due  to  the  memory  of 
Miss  Robbins,  who,  alone  and  without  the  guidance  of  precedent 
and  unsupported  by  the  experience  of  others,  more  than  fifty  years 
ago  founded  a  work  which  brought  not  only  relief  from  suffering 


I 


BRADFORD.  IO3 

and  favored  the  ultimate  cure  of  hundreds,  but  also  developed 
an  institution  which,  for  skill  and  economy  of  administration, 
breadth  of  charitable  effort  and  value  of  the  work  accomplished, 
might  serve  as  a  model  even  now  to  a  generation  which  is  enjoying 
the  benefit  of  all  that  experience  has  taught  in  the  last  half- 
century.  The  work  so  wisely  begun  by  Miss  Robbins  did  not 
cease  with  her  death,  but  by  the  co-operation  of  her  friends  has 
continued.  The  institution  grew  into  the  admirable  Samaritan 
Hospital,  at  present  maintained  in  Boston  for  the  treatment  of 
all  chronic  affections. 

BOSTON   CHILDREN'S   HOSPITAL. 

When  the  Boston  Children's  Hospital  was  established  in  1869 
it  became  evident  that  the  treatment  of  bone  tuberculosis  would 
be  demanded  in  the  institution,  and  the  results  have  justified  this 
original  opinion.  The  treatment  of  surgical  tuberculosis,  and 
especially  of  the  larger  joints  and  of  the  spine,  has  been  an  im- 
portant feature  of  the  work  of  the  institution.  As  a  continued 
and  systematic  treatment  of  these  affections  has  been  made  at 
the  Boston  Children's  Hospital  for  a  number  of  years  under  the 
same  direction,  the  improved  results  enable  the  observer  to  esti- 
mate the  great  advance  that  can  be  recorded  in  the  treatment  of 
bone  tuberculosis. 

The  progress  in  the  treatment  of  bone  tuberculosis  can  be 
well  illustrated  by  a  comparison  of  the  results  now  obtained  with 
those  recorded  twenty  or  thirty  years  ago.  For  example,  the 
mortality  of  hip  disease  at  the  hospital  in  Tiibingen  was  40 
per  cent.;  at  Kiel,  48  per  cent,  non-operative  cases,  53  per  cent, 
operative  cases;  at  Marburg,  35  per  cent,  non-operative  cases, 
40  per  cent,  operative  cases;  at  Heidelberg,  46  per  cent,  non- 
operative  cases,  58  per  cent,  operative  cases;  in  Zurich,  37 
per  cent,  non-operative  cases,  54  per  cent,  operative  cases;    in 


104  TUBERCULOSIS    IN    MASSACHUSETTS. 

Vienna,  17  per  cent,  in  all  cases;  in  Gbttingen,  a  mortality  of  40 
per  cent.;  at  the  Alexandra  Hospital  in  London  the  mortality  was 
26  per  cent.  These  statistics  represent  the  mortality  of  hip  disease 
from  twenty  to  forty  years  ago,  i.e.,  before  the  introduction  of  the 
modern  methods  of  treatment  in  seashore  sanatoria  and  conva- 
lescent homes.  From  such  meager  statistics  as  exist,  the  American 
mortality  from  hip  disease  twenty  years  ago  was  estimated  as 
from  12  per  cent,  to  25  per  cent.  This  included  death  from  various 
causes  connected  with  the  original  tuberculous  coxitis;  namely, 
tuberculous  meningitis,  septicaemia,  septic  nephritis,  etc.  In  con- 
trast to  this,  the  latest  statistics  in  the  Boston  Children's  Hospital, 
giving  the  ultimate  results  of  cases  treated  ten  years  ago,  show  a 
mortality  of  only  4  per  cent,  from  all  causes.  This  diminution  of 
the  death-rate  may  be  fairly  attributed  in  large  part  to  improved 
methods  in  surgical  treatment,  as  well  as  to  better  opportunities 
for  out-door  life,  fresh  air  and  activity.  Statistics  of  mortality, 
however,  do  not  indicate  the  only  benefit  which  has  followed 
surgical  treatment  in  these  forms  of  bone  tuberculosis;  even  more 
marked  are  the  limitations  of  the  ravages  of  the  disease,  and 
the  securing  of  ultimate  results  which  ensure  freedom  from 
deformity  and  great  disability.  Those  who  have  observed  the 
gradual  advance  in  the  success  in  treatment  can  testify  further  to 
the  less  formidable  character  of  the  affection  as  it  is  now  brought 
for  treatment.  This  is  in  part  due  to  the  general  improvement 
in  public  health,  but  largely  to  the  earlier  recognition  of  the 
disease  and  the  better  facilities  for  early  and  thorough  treatment. 
This  fact,  so  noticeable  in  this  community,  is  confirmatory  of  what 
has  been  observed  in  other  places  where  careful  attention  is  paid 
to  the  care  of  this  class  of  cases. 

A  similar  statement  can  be  made  in  regard  to  Pott's  disease, 
which,  next  to  pulmonary  tuberculosis,  is  the  most  formidable 
of  all  the  tuberculous  affections.     It  may  be  said  that  at  present. 


BRADFORD.  IO5 

under  proper  medical  care,  there  should  be  no  hump-backs,  and 
that  the  mortality,  which  in  the  hands  of  the  surgeons  of  the  past 
generation  was  formidable,  is  now  reduced  to  what  may  result 
from  an  attack  of  another  disease  or  the  entrance  of  a  complication. 

The  advances  in  the  methods  of  treatment  consist  not  only  in 
improvement  in  surgical  intervention  and  in  improved  methods 
in  the  correction  and  prevention  of  deformity,  but  also  in  better 
methods  in  the  treatment  of  the  local  condition  and  in  the  care  and 
nurture  of  the  patient. 

When  it  was  generally  believed  that  diseased  bone  could  not 
heal  and  was  a  foreign  body  causing  irritation,  the  surgeon's  re- 
course to  the  knife  was  necessarily  extensive.  Now  that  repara- 
tive power  in  diseased  bone  tissue  under  certain  circumstances 
has  been  recognized,  not  only  is  there  a  greater  reliance  upon 
conservative  measures,  but  operative  procedures  are  less  commonly 
and  more  carefully  performed.  The  use  of  the  Roentgen  rays 
has  given  both  greater  precision  to  operative  interference  and  a 
sounder  judgment  in  having  recourse  to  it. 

Experience  with  appliances  and  in  the  use  of  plaster  bandages, 
a  more  thorough  knowledge  of  the  nature  of  bone  tuberculosis, 
when  rest  should  be  enforced,  when  activity  is  safe,  have  given 
the  surgeon  greater  elasticity  in  his  methods,  and  enabled  him  to 
employ  with  greater  freedom  the  general  methods  of  proved  ad- 
vantage in  combating  the  tuberculosis  and  therefore  in  promoting 
a  cure.  The  advance  in  the  therapeusis  of  bone  tuberculosis  will 
be  best  understood  if,  not  forgetting  earlier  pathological  teachings, 
the  present  theory  of  treatment  is  explained. 

While  it  is  universally  admitted  that  the  best  treatment  for 
tuberculous  affections  is  fresh  air  and  such  an  environment  as 
promotes  healthy  nutrition,  —  in  other  words,  those  conditions 
which  aid  in  the  development  of  sound  tissue,  —  yet,  in  bone 
tuberculosis  other  factors  of  almost  equal  importance  cannot  be 


I06  TUBERCULOSIS    IN    MASSACHUSETTS. 

overlooked.  While  tuberculosis  of  bone,  if  undisturbed,  heals  as 
does  tuberculosis  elsewhere,  it  is  evident  that,  owing  to  the  rigid 
nature  of  the  bone  and  the  inability  of  the  cicatricial  tissue  to 
shrink  the  previously  diseased  structure  into  a  small  cicatrix  of 
fibrous  tissue,  an  extensively  diseased  bone,  if  the  detritus  of  dis- 
organized tissue  is  thrown  off,  leaves  a  gap  which  must  be  filled  by 
resistant  bone  before  a  healthy  bone  substance  capable  of  with- 
standing tuberculous  invasion  is  established.  This  latter  process 
needs  an  adequate  amount  of  time;  and  time,  therefore,  becomes 
an  important  element  in  the  care  and  cure  of  bone  tuberculosis. 
Again,  where  a  tuberculous  tissue  is  exposed  to  constant  bruising, 
the  impaired  cell  development  which  follows,  as  well  as  the  con- 
tused tissue,  furnishes  an  excellent  nidus  for  the  development  of 
tuberculous  germs.  This  is  well  shown  by  the  fact  that  tubercu- 
losis of  the  upper  extremities  is  less  destructive  and  more  easily 
arrested  than  the  same  infection  of  the  larger  joints  of  the  lower 
extremities  or  in  the  spinal  column.  It  is  important,  therefore, 
that  all  injury  to  the  diseased  tissue  be  avoided.  It  is  for  this 
reason  that  Pott's  disease  and  hip  disease  were  for  many  years 
considered  incurable.  The  surgeon  was  unable,  on  account  of  the 
faulty  means  at  his  disposal,  to  prevent  the  patient  from  being 
subject  to  repeated  injury  of  the  diseased  structure,  except  by 
retention  in  bed  or  close  confinement.  Protection  from  injury 
which  involved  the  retention  of  the  patient  in  bed  for  years,  or 
for  a  long  period,  was  not  favorable  to  the  proper  metabolism, 
and  was  in  itself  an  evil.  With  improved  methods  of  fixation,  the 
surgeon,  however,  is  enabled  with  safety  to  take  advantage  of 
both  therapeutic  agencies,  —  protection  from  jar  and  freedom 
from  confinement. 


I 


BRADFORD.  IO7 

WELLESLEY    CONVALESCENT    HOME    OF    THE    BOSTON   CHIL- 
DREN'S   HOSPITAL. 

Cases  of  bone  tuberculosis  are  especially  benefited  by  the  fresh- 
air  treatment,  as  has  been  shown  in  many  instances.  The  ex- 
perience of  the  Wellesley  Convalescent  Home  will  serve  as  an 
admirable  illustration.  For  several  years  the  Convalescent  Home 
consisted  of  a  comfortable,  well-arranged  building,  with  the  health- 
ful surroundings  found  in  a  well-aired  and  well-drained  farm.  All 
the  children  showing  constitutional  enfeeblement  were  sent  from 
the  Children's  Hospital  to  the  Convalescent  Home  when  active 
surgical  treatment  was  not  needed.  The  fresh  air  furnished  was 
simply  that  which  was  to  be  obtained  from  the  out-of-door  play, 
and  in  rooms  well  aired  by  window  ventilation.  After  some  years 
the  management  of  the  Convalescent  Home  determined  to  give 
children  suffering  from  surgical  tuberculosis  the  advantage  of 
fresh-air  treatment  in  shacks.  Circumstances  delayed  the  first 
attempt  until  the  winter  months,  and  the  patients  were  therefore 
placed  in  the  shacks  during  the  cold  weather.  The  results  have 
been  so  gratifying  that  the  open-air  method  of  treatment  has 
become  the  established  one  for  suitable  cases  of  surgical  tuber- 
culosis for  both  summer  and  winter. 

Tabulation  of  the  increase  in  the  percentage  of  haemoglobin  and 
weight  in  thirteen  cases  of  tuberculosis  of  the  knee,  hip  and  spine 
thus  treated  shows  very  striking  results.  It  was  found  that  cases 
suffering  from  open  abscesses  did  not  show  the  improvement  that 
was  seen  in  cases  where  no  surgical  irritation  existed.' 

It  is  evident  that  in  the  surgical  treatment  of  bone  tuberculosis 
the  indications  for  surgical  interference  must  vary  with  the  locality 
attacked.  The  treatment  of  tuberculosis  of  the  vertebral  bodies 
will  necessarily   be  different   from   that   of  tuberculosis  of   the 

1  Dr.  John  L.  Adams,  "  A  Report  of  Seventeen  Cases  in  Open-air  Treatment  for  Surgical  Tuber- 
culosis in  Children."     Bost.  M.  &  S.  J.,  1906,  CLIV,  71. 


I08  TUBERCULOSIS    IN    MASSACHUSETTS.  — 

Sternum.  Tuberculosis  first  attacks  the  spongy  portion  of  the 
bone  and  by  preference  that  portion  of  the  spongy  portion  where 
the  development  of  new  cells  is  likely  to  take  place,  namely, 
the  epiphyses  or  the  juxta-epiphyseal  line.  Hard,  dense  bone  is 
resistant  to  the  tuberculous  invasion.  The  spreading  of  tuber- 
culosis in  bone  is  probably  not  rapid,  and  is  usually  accom- 
panied by  the  development  of  cicatricial  bone  tissue  surrounding 
the  focus  or  the  portion  invaded.  The  constructive  cicatricial 
osteitis  in  the  majority  of  cases  establishes  a  cure  by  the  encysting 
of  the  tuberculous  mass,  and  by  the  gradual  substitution  of  dense 
cicatricial  bone  for  the  diseased  spongy  bone  tissue.  The  surgical 
treatment  should  therefore  be  directed  toward  aiding  this  natural 
tendency  to  cicatrization,  rather  than  interrupting  it.  In  ex- 
tensive bone  tuberculosis  the  periarticular  tissues  of  the  capsules 
of  the  synovial  membrane  usually  become  involved  and  at  times 
all  motion  of  the  joint  is  painful.  When,  however,  cicatrization 
and  cure  have  been  nearly  established,  some  motion  at  the  joint 
is  not  only  harmless  but  may  be  beneficial. 

The  danger  of  mixed  infection  is  not  to  be  overlooked  in  bone 
tuberculosis.  It  has  been  shown  that  in  the  majority  of  fatal 
cases  of  joint  tuberculosis  death  does  not  result  from  tuberculous 
generalization,  but  from  a  septicaemia  due  to  secondary  infection 
of  the  tissues  previously  affected  by  tuberculosis.  The  application 
of  this  fact  to  operative  treatment  is  evident. 

The  special  surgical  procedures  and  appliances  to  be  used  in  the 
tuberculous  affections  of  different  joints  do  not  come  within  the 
scope  of,  and  are  not  described  in,  this  article,  but  the  absence  of 
any  description  here  need  not  be  construed  as  indicating  a  lack  of 
the  sense  of  importance  of  surgical  measures.  In  bone  tuber- 
culosis constitutional  treatment  alone  is  but  partially  curative. 
Where  surgical  measures  are  thoroughly  carried  out,  the  best 
results  can  be  anticipated. 


BRADFORD.  IO9 

The  subject  of  the  general  treatment  of  tuberculosis  will  also 
not  be  considered  here,  for  the  reason  that  bone  tuberculosis  as 
considered  in  this  chapter  is  to  be  regarded  as  amenable  to  the 
same  general  treatment  that  is  found  of  advantage  in  tuberculosis 
elsewhere  in  the  body. 

The  present  surgical  treatment  of  bone  tuberculosis  may  be 
regarded  as  having  developed  over  that  of  the  past  to  the  extent 
of  retaining  the  essence  of  that  which  was  useful  in  past  surgery, 
with  the  addition  of  what  modern  science  has  taught  us.  The 
fixation  and  protection  of  the  joints  are  important  at  certain 
stages,  namely,  the  stage  of  acute  invasion  and  of  progressive 
disease;  but  they  are  not  indicated  in  all  stages,  and  greater 
freedom  should  be  allowed  in  the  convalescent  stages,  where  the 
exercise  and  hyperzemia  of  slight  motion  is  found  to  be  of  ad- 
vantage in  restoring  function  to  the  cicatrized  periarticular  tissues. 
Counter-irritants,  which  were  formerly  regarded  as  of  so  great 
value,  are  now  replaced  by  hyperaemia  treatment,  which  is  of 
benefit  in  reducing  the  sluggish  congestion  of  swollen  periarticular 
tissue.  Operative  interference  is  of  proved  value  in  advanced 
cases  with  marked  necrosis,  and  the  usefulness  of  perfected  mech- 
anisms in  the  prevention  of  deformity  has  been  abundantly  shown. 

Little  need  be  said  here  regarding  the  tuberculous  invasion  of 
other  tissues  which  frequently  come  under  the  surgeon's  care. 
Tuberculous  periosteitis,  tuberculous  involvement  of  the  glands, 
tuberculosis  of  the  kidney,  of  the  testes  and  the  prostate,  of  the 
mesenteric  glands  and  larynx  may  all  be  classed  as  surgical  tuber- 
culosis. But,  like  bone  tuberculosis,  the  surgical  treatment  varies 
with  the  locality  invaded,  and  needs  special  surgical  consideration 
as  to  the  question  of  surgical  interference.  In  these,  as  in  all 
forms  of  tuberculosis,  the  treatment  of  the  patient's  general  con- 
dition should  be  the  first  consideration. 


no  TUBERCULOSIS    IN    MASSACHUSETTS. 

GENERAL   CONSIDERATIONS. 

The  subject  of  bone  and  joint  tuberculosis  needs,  in  addition  to 
the  study  of  the  results  of  treatment  of  individual  cases,  the 
broader  consideration  of  the  subject,  especially  the  relation  of  the 
affected  individual  to  the  community,  and  what  steps  the  com- 
munity should  take,  not  only  for  the  care  of  the  individual  afflicted, 
but  also  for  the  protection  of  other  individuals-,  especially  among 
the  poorer  classes. 

The  first  and  most  important  consideration  is:  Should  cases  with 
bone  and  joint  tuberculosis  be  isolated,  or  to  what  extent  are  they 
to  be  isolated?  The  fear  of  tuberculosis  which  has  recently  be- 
come so  evident  in  our  communities  is  such  that  the  doors  of  many 
charitable  institutions  are  closed  against  even  bone  tuberculosis. 
It  is  important,  therefore,  to  learn  to  what  extent  there  is  danger 
to  the  inmates  of  such  an  institution  from  the  presence  of  patients 
with  bone  tuberculosis.  There  can  be  no  doubt  that  the  danger 
of  contagion  from  bone  tuberculosis  is  greatly  exaggerated,  if  any 
danger  at  all  exists.  It  is  not  conceivable  that  a  patient  suffering 
from  a  tuberculous  focus  in  one  of  the  vertebral  bodies,  that  is,  in 
the  anterior  portion  of  the  spinal  column,  without  a  discharging 
sinus,  can  serve  as  a  source  of  infection.  There  would  appear  to 
be  no  danger  in  the  admission  of  such  patients  into  the  wards  of 
a  general  hospital  or  convalescent  home.  All  these  affections 
differ  entirely  from  pulmonary  tuberculosis,  where  the  sputum 
is  a  ready  carrier  of  contagion.  It  is  to  be  remembered  that  in 
bone  tuberculosis,  where  abscesses  have  developed,  with  discharg- 
ing sinuses,  the  tuberculous  process  is  usually  accompanied  by  the 
complication  of  streptococcic  bone  involvement,  which  largely 
transforms  the  tuberculous  osteitis  into  a  septic  osteomyelitis. 
It  is  possible  that  the  pus-forming  organisms  in  septic  osteomye- 
litis may  destroy  the  virulence  of  the  tubercle  bacillus  to  such  an 


BRADFORD.  1 1  I 

extent  that  the  danger  of  contagion  is  small.  If  any  danger  does 
exist,  it  can  be  easily  overcome  by  the  use  of  ordinary  surgical 
dressings.  In  fact,  it  may  be  said  that  where  common  surgical 
care  is  provided  there  can  be  no  danger  to  the  inmates  of  an  insti- 
tution from  the  admission  of  patients  suffering  from  bone  tuber- 
culosis. 

It  is  undoubtedly  of  advantage  in  most  institutions  to  separate 
children  from  adults,  especially  from  those  with  pulmonary  tuber- 
culosis; and  it  is  for  these  reasons  that  the  surgical  treatment  of 
bone  tuberculosis  properly  falls  within  the  province  of  the  chil- 
dren's hospitals,  as  by  far  the  greater  number  of  patients  suffering 
from  bone  tuberculosis  are  children,  and  need  different  surround- 
ings from  those  necessary  for  adults. 

Home  Care  Versus  Institution  Care.  —  As  the  majority  of  these 
cases  occur  in  childhood,  there  can  be  no  doubt  that  home  sur- 
roundings, when  favorable,  furnish  the  best  environment  for 
children  and  are  much  preferable  to  institution  care.  These 
conditions  are  not  always  possible  among  the  poor,  or  even  the 
well-to-do,  and  for  this  reason  a  large  number  of  cases  of  bone 
tuberculosis  need  institution  treatment  for  a  portion  of  the  time 
during  the  active  stage.  It  must  be  admitted  that  efficient  care 
of  the  patient  suffering  from  caries  of  the  spine  or  tuberculosis  of 
the  hip  involves  a  considerable  tax  upon  the  nursing  resources  of 
the  home.  A  compromise  is  possible  in  most  instances,  where  a 
short  period  of  institution  care  may  be  followed  by  intelligent 
home  care  under  direction  and  supervision. 

Convalescent  Homes.  —  The  value  of  these  institutions  in  the 
treatment  of  bone  tuberculosis  can  hardly  be  exaggerated.  Few 
private  homes  furnish  the  requirements  of  fresh  air  and  activity 
which  can  be  given  in  properly  regulated  convalescent  homes, 
where  the  conditions  can  be  made  to  conform  to  the  requirements 
demanded  by  the  surgical  indications  of  the  patients.     Residence 


112  TUBERCULOSIS    IN    MASSACHUSETTS. 

in  a  convalescents'  home  should  be  limited  to  those  cases  where 
proper  home  care  cannot  be  carried  out,  it  being  an  aphorism  in 
all  charitable  work  that  it  is  an  unwise  policy  to  remove  children 
from  home  influences. 

Seashore  Versus  Country  Convalescent  Homes.  —  There  has 
existed  a  general  feeling  that  the  sea  air  is  especially  beneficial  to 
bone  tuberculosis,  which  may  be  likened  to  the  former  belief  as 
to  the  superiority  of  mountain  air  over  that  of  sea  air  for  pulmonary 
tuberculosis.  It  is  difficult  to  state  definitely  what  foundation 
exists  for  the  belief  in  the  superiority  of  sea  air  over  that 
of  pure  air  of  internal  localities.  It  is  probable  that  the  benefit 
to  be  derived  from  seashore  homes  is  that  during  the  hot  season 
the  heat  is  tempered  by  sea  breezes,  and  the  patients  are  not 
obliged  to  remain  housed  for  protection  from  the  intense  heat. 
It  would  appear  reasonable  to  suppose  that  the  question  of  a 
country  convalescent  home  or  a  seashore  convalescent  home  is 
a  geographical  rather  than  a  theoretical  one.  A  convalescent 
home  should  be  so  located  as  to  enable  the  patients  to  enjoy  the 
benefit  of  pure  air  and  a  maximum  of  sunshine  for  as  long  a  period 
as  possible.  There  can  be  no  question  of  the  advantages  of  sea- 
shore homes  during  the  hot  season  of  the  year,  provided  they 
are  well  protected,  and  allow  the  proper  amount  of  freedom 
from  any  source  of  tuberculous  contagion. 

School  Hours  for  Patients  with  Bone  Tuberculosis.  —  As  bone 
tuberculosis  in  its  usual  form  requires  for  its  complete  cure  a  long 
period  of  time,  children  would  be  deprived  of  educational  ad- 
vantages if  during  the  convalescent  stage  they  were  unable  to 
attend  school.  Such  children  should  not  only  be  free  from  any 
tax  upon  their  constitutional  strength,  but  also  from  the  rougher 
play  incident  to  large  schools.  It  is  for  this  reason  that  special 
arrangement  of  school  work  is  advisable  for  children  who  are 
suffering  from  bone  tuberculosis  in  the  acute  or  the  convalescent 


I 


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BRADFORD.  II3 

Stage.  This  can  be  met  by  the  education  of  these  children  by 
means  of  tutors,  or  by  the  establishment  of  special  schools.  Of 
these,  two  examples  can  be  found  in  the  Boston  Industrial  School 
for  Crippled  and  Deformed  Children,  and  in  the  Massachusetts 
State  Hospital  School  at  Canton.  The  children  in  institutions 
of  this  class  should  be  furnished  not  only  with  proper  instruction, 
but  the  hours  of  play  should  also  be  regulated  and  physical  culture 
provided. 

MASSACHUSETTS    INSTITUTIONS    FOR    THE    CARE    OF    SURGI- 
CAL  TUBERCULOSIS. 

The  excellent  facilities  for  the  care  of  surgical  tuberculosis  at 
present  available  in  Massachusetts  indicate  that  attention  has  been 
called  of  recent  years  to  the  need  of  improved  care  of  these  patients. 

The  Good  Samaritan  Hospital  has  accommodations  for  twenty- 
five  cases  of  surgical  tuberculosis,  and  facilities  for  open-air  treat- 
ment. It  is  important  to  note  that  this  treatment  is  provided  in 
an  institution  where  other  forms  of  tuberculosis  and  chronic  dis- 
eases are  also  treated. 

The  Boston  Children's  Hospital,  with  an  out-patient  service  of 
twenty-one  thousand  cases  yearly,  one-fifth  of  which  may  be  esti- 
mated as  surgical  tuberculosis,  contains  fifty  beds  for  surgical 
cases. 

The  Convalescent  Home  of  the  Children's  Hospital  has  accom- 
modations for  seventy-five  patients,  from  one-half  to  two-thirds 
of  which  are  surgical  tuberculosis.  In  co-operation  with  this  insti- 
tution is  the  Day  School  for  Crippled  and  Deformed  Children,  on 
St.  Botolph  Street.  This  is  supported  by  voluntary  contributions. 
It  was  founded  in  1896,  and  accommodates  seventy-five  pupils. 

The  Commonwealth  of  Massachusetts,  recognizing  the  need  of 
providing  for  the  care  of  cases  of  this  character,  has  recently  estab- 
lished a  State  Hospital  School  for  Crippled  Children,  at  Canton,  where 


114  TUBERCULOSIS    IN    MASSACHUSETTS. 

care,  nursing  and  instruction  are  furnished  to  children  who  are 
crippled  and  deformed,  without  mental  disability.  The  institution 
was  opened  in  1908,  and  furnishes  accommodations  for  one  hun- 
dred and  twenty  inmates. 

An  excellent  private  institution  has  been  established  in  Hyde 
Park,  where  children  with  surgical  tuberculosis  are  cared  for. 
The  institution,  which  is  supported  by  voluntary  contributions, 
is  incorporated  under  the  name  of  the  Pedbody  Home  for  Crippled 
and  Deformed  Children.     It  has  from  thirty  to  forty  inmates. 

Another  admirable  institution,  the  Baldwinsville  Home,  at  Bald- 
winsville,  receives  a  certain  number  of  children  suffering  from 
surgical  tuberculosis.     It  is  a  private  institution. 

The  Lowell  Island  Seashore  Home  for  two  months  during  the 
summer  receives  and  cares  for  cases  of  surgical  tuberculosis. 

Similar  care  is  furnished  at  the  Burrage  Hospital,  in  Boston 
harbor,  which  is  open  during  the  months  of  July,  August  and  a 
part  of  September. 

At  present  the  larger  general  hospitals,  notably  the  Carney  and 
the  Massachusetts  General  hospitals,  furnish  surgical  care  for  cases 
of  surgical  tuberculosis. 

Although  the  number  of  patients  suffering  from  surgical  tuber- 
culosis cared  for  in  the  above  institutions  is  considerable,  it  is 
evidently  desirable  that  similar  provision  be  made  locally  in  all 
the  larger  cities  of  our  Commonwealth  for  the  early  recognition  of 
all  forms  of  tuberculosis,  and  for  the  proper  early  surgical  treat- 
ment as  well  as  suitable  hygienic  surroundings. 


LOCKE.  115 


Chapter  X. 

THE  WORK  OF  THE  COMMUNITIES  THROUGHOUT  THE 

STATE. 

Edwin  A.  Locke,  M.D. 

With  few  exceptions,  but  little  has  been  undertaken  individually 
by  the  cities  and  towns  of  the  Commonwealth  to  combat  tubercu- 
losis. The  gratifying  development  of  the  widespread  activity 
against  tuberculosis  in  Massachusetts  has  been  the  result  almost 
solely  of  the  efforts  of  voluntary  associations  and  individuals,  and 
in  the  few  instances  where  the  community  as  a  community  has 
been  aroused  to  face  its  responsibility  in  the  matter,  it  has  been 
in  consequence  directly  or  indirectly  of  previous  voluntary  work. 
The  organization  of  these  associations  and  their  achievements 
have  been  described  in  Chapter  XI. 

The  fact  that  the  control  of  tuberculosis  is  essentially  a  sanitary 
and  social  problem  which  can  be  successfully  solved  only  by  the 
communities  acting  in  close  co-operation  with  all  other  agencies 
is  becoming  more  and  more  generally  recognized,  and  the  next  few 
years  promise  a  great  awakening  on  the  part  of  the  cities  and 
towns  of  the  State  to  their  duty  in  this  regard.  Many  plans  for 
activities  along  the  various  lines  are  either  contemplated  or  actu- 
ally under  way  in  many  quarters  of  the  State. 

The  activities  of  the  State  Board  of  Health  and  its  relation  to 
the  local  boards  have  been  discussed  in  Chapter  II.  As  mentioned 
there,  in  accordance  with  the  order  of  the  State  Board  of  Health  of 
August  I,  1907,  tuberculosis  in  all  its  forms  is  included  in  the  group 
of  diseases  considered  dangerous  to  the  community.  Notification 
of  all  cases  of  tuberculosis  to  the  local  boards  of  health  is  therefore 
compulsory  throughout  the  State. 


ii6 


TUBERCULOSIS    IN    MASSACHUSETTS. 


Aside  from  Boston,  no  city  or  town  in  the  Commonwealth  main- 
tains a  special  hospital  for  tuberculosis,  but  in  three  a  limited 
number  of  beds  is  provided  in  the  city  institutions  for  the  sick 
(Worcester,  Lawrence  and  Brookline).  The  city  of  Haverhill  has 
made  provisions  for  the  care  of  a  small  number  of  advanced  con- 
sumptives in  the  discarded  polling  booths.  Special  tuberculosis 
clinics  have  been  established  at  the  Worcester  City  Hospital, 
Lowell  General  Hospital  and  Fall  River  City  Hospital. 

Systematic  inspection  of  school  children,  in  most  instances  com- 
bined with  examination,  is  carried  out  in  the  following  cities  and 
towns:  Andover,  Brockton,  Brookline,  Cambridge,  Chelsea,  Fall 
River,  Fitchburg,  Haverhill,  Holyoke,  Lawrence,  Lynn,  Maiden, 
New  Bedford,  Newton,  Northampton,  Pittsfield,  Somerville, 
Springfield,  Taunton,  Walpole,  Waltham,  Ware,  Winchester,  Wo- 
burn  and  Worcester. 

Early  in  the  present  year  the  city  of  Cambridge  appropriated 
$20,000  for  the  erection  and  maintenance  of  a  permanent  day- 
camp  for  consumptives,  to  be  under  the  direction  of  the  Cambridge 
Board  of  Health.  This  institution  was  opened  July  15,  with  a 
capacity  for  one  hundred  patients.  The  administration  is  under 
a  corps  of  visiting  physicians  and  a  salaried  resident  |5hysician. 
The  city  of  Cambridge  has  also  for  the  past  few  years  through  its 
Board  of  Health  treated  a  considerable  number  of  advanced  con- 
sumptives at  the  Holy  Ghost  and  other  hospitals,  and  has  fur- 
nished financial  aid  to  residents  of  Cambridge  going  to  various 
sanatoria. 

Andover,  Canton,  Everett,  Haverhill,  Milton,  Newton,  North- 
ampton and  Ware  have  also  aided  needy  cases  going  to  the  State 
Sanatorium  at  Rutland  directly  from  city  funds. 

The  results  obtained  in  the  town  of  Oxford  are  so  extraordinary 
as  to  merit  special  mention.  In  a  recent  paper  Dr.  Elliot  P.  Joslin 
has  given  a  very  complete  report  of  his  careful  study  of  the  con- 


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LOCKE. 


117 


ditions  there  and  of  the  results  accompHshed.'  Oxford  is  a  small 
manufacturing  town  of  about  three  thousand  inhabitants.  Dur- 
ing the  period  from  185 1  to  1900  the  average  death-rate  from 
consumption  was  32.7  per  10,000  inhabitants,  or  considerably 
higher  than  the  average  death-rate  throughout  the  State  of 
Massachusetts.  The  striking  decrease  in  this  death-rate  is  well 
shown  in  the  following  table:  — 


PERIODS. 

Total  Number 

of  Deaths  from 

Consumption. 

Number  of  Deaths 

from  Consumption  per 

10,000  Inhabitants. 

1851-55,     . 
1856-60,     . 
1861-65,     . 
1866-70.     . 

41 
64 

87 

43 

3' 
43 
60 

3' 

6 

7 
5 
2 

1871-75,     . 
1876-80,     . 
1881-85,     . 
1886-90,     . 

59 
40 
42 
32 

42 
28 

33 

25 

0 

7 
8 

7 

1891-95,     . 
1 896- 1 900, 

30 

25 

23 
19 

9 

7 

1901-05,     . 
1906, 

'9 

>3 

6 

1907. 

4 

'3-7 

The  ages  of  those  dying  from  tuberculosis  in  Oxford  during  1907 
were  twenty-six,  forty-seven,  sixty-three  and  seventy-seven  respec- 
tively, and  of  these  four  individuals  one  was  only  a  temporary 
resident.  This  shows  strikingly  how  few  new  cases  are  appearing 
in  the  town. 

Although  this  decrease  was  undoubtedly  the  result  in  a  large 
measure  of  such  factors  as  the  general  improvement  in  the  living 
conditions  of  the  poor,  it  seems  fair  to  attribute  the  very  marked 
fall  in  the  death-rate  during  the  past  seven  years  to  the  vigorous 
campaign  carried  on  against  the  disease  on  the  part  of  the  au- 
thorities of  the  town  and  some  of  its  citizens.    The  A.  P.  Joslin 


1  Best.  Med.  &  Surg.  Jour.,  1905.     CLIII,  436. 


Il8  TUBERCULOSIS    IN    MASSACHUSETTS. 

Company  has  been  especially  active  in  investigating  conditions 
in  its  factory,  and  in  caring  for  any  cases  found  among  the  em- 
ployees. Various  notices,  calling  attention  to  the  prevalence  of 
the  disease,  the  proper  measures  to  be  taken  to  control  it,  describ- 
ing the  symptoms  of  the  disease  and  urging  all  employees  with 
suspicious  symptoms  to  consult  a  physician,  are  posted  in  the 
factory.  Relief  to  the  families  of  the  consumptives  is  given,  and 
the  firm  agrees  to  pay  the  board  in  a  sanatorium  for  at  least  three 
months  of  any  case  appearing  among  those  employed. 

THE   ANTI-TUBERCULOSIS   WORK   ORGANIZED    BY  THE   CITY 

OF   BOSTON. 

Boston  is  the  only  city  in  the  entire  State  which  has  inaugurated 
a  comprehensive  municipal  anti-tuberculosis  movement.  A  full 
account  of  this  organization  was  recently  published  in  the  second 
annual  report  of  the  Consumptives'  Hospital  Department  of  the 
City  of  Boston,  1907,  and  a  further  account  in  the  Transactions 
of  the  National  Association  for  the  Study  and  Prevention  of 
Tuberculosis,  1908,  of  which  the  following  is  an  abstract. 

The  assumption  of  this  work  by  the  city  is  a  direct  outgrowth  of 
the  many  years  of  splendid  activity  in  this  community  on  the  part 
of  many  private  agencies  and  the  efforts  of  individual  phy- 
sicians. 

The  needs  of  this  broader  work  become  more  evident  if  the  con- 
ditions in  Boston  are  briefly  considered.  According  to  the  latest 
estimates,  Boston  has  a  population  of  609,757.  For  the  year  1907 
the  general  death-rate  per  10,000  inhabitants  was  191 .67,  of  which 
9|  per  cent.,  or  18.42  per  10,000,  were  due  to  tuberculosis.  Chart 
I  shows,  in  terms  of  the  number  of  deaths  per  10,000  inhabitants, 
the  decrease  in  the  death-rate  from  consumption  since  1846.  It 
will  be  seen  that  the  past  twenty-one  years  marks  a  diminution 


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CHART   1.- SHOWING    DEATH-RATE    FROM    PULMONARY    TUBERCULOSIS    IN    BOSTON    FROM    184*    TO    1906. 


LOCKE.  119 

of  approximately  55  per  cent,  in  the  number  of  yearly  deaths  from 
this  single  cause.  This  decrease  represents  an  actual  saving  of 
14,412  lives. 

In  spite  of  this  gratifying  fall  in  the  death-rate,  the  total  num- 
ber of  deaths  from  all  forms  of  tuberculosis  in  1907  was  1,358.  As 
is  well  known,  this  occurred  largely  among  the  poorer  class.  In 
the  absence  of  any  reliable  morbidity  statistics,  the  exact  number 
of  cases  of  tuberculosis  in  the  city  cannot  be  stated,  but  1  believe 
we  have  sufficient  basis  for  the  estimate  that  there  are  at  least 
10,000  and  probably  15,000  consumptives  in  the  city  of  Boston. 
For  the  care  of  these  cases,  the  total  number  of  beds  in  all  institu- 
tions for  consumptives  previous  to  the  beginning  of  the  present 
work  was  775;  2,131  patients  were  treated  in  these  beds  during 
the  year  1907,  and  approximately  800  were  examined  in  the  four 
special  tuberculosis  clinics. 

The  urgent  need  of  greater  hospital  accommodations  for  those 
affected  with  tuberculosis  has  for  many  years  been  apparent,  and 
in  1901  an  appropriation  of  1150,000  was  finally  made  by  the  city 
government.  This  sum  seemed  so  inadequate,  however,  that  for 
many  years  it  was  not  made  available. 

The  real  beginning  of  the  present  work  was  made  five  years 
later,  in  the  creation  of  a  Consumptives'  Hospital  Department  by 
the  City  Council,  and  the  appointment  of  an  unpaid  Board  of 
seven  Trustees  by  Mayor  Fitzgerald,  who  were  empowered  to 
purchase  land  and  to  erect  and  maintain  a  hospital  for  consump- 
tives. As  a  means  of  affording  immediate  relief,  pending  the 
erection  of  the  hospital,  the  Board  of  Trustees  were  authorized 
by  a  special  act  of  the  State  Legislature  to  "hire  not  more  than 
one  hundred  beds  in  private  hospitals  and  to  pay  not  more  than 
five  dollars  a  week  per  patient  for  the  use  of  needy  tuberculous 
patients  who  are  residents  of  said  city."     Up  to  the  present  time 


120  TUBERCULOSIS    IN    MASSACHUSETTS. 

the  city  of  Boston  has  appropriated  $307,000  for  buildings.  For 
the  maintenance  of  the  work  thus  organized,  the  city  has  for  the 
present  year  made  an  appropriation  of  1 100,000.  I 

Realizing  the  magnitude  of  the  task  and  the  ineflFectiveness  of 
individual  efforts,  the  trustees  have  sought  to  build  up  a  compre- 
hensive organization  which  shall  so  co-ordinate  all  factors  in  the 
work,  both  public  and  private,  as  to  effectively  deal  with  all  phases 
of  the  problem.  Success  demands  sustained  efforts  along  many 
lines  for  a  long  period  of  years.  The  Boston  Board  of  Health, 
the  various  hospitals  for  the  care  of  advanced  consumptives,  sana- 
toria, special  tuberculosis  clinics,  convalescent  homes  and  many  | 
other  agencies,  such  as  the  volunteer  associations.  Associated 
Charities  (comprising  over  sixteen  hundred  different  societies), 
churches,  women's  clubs,  labor  unions,  etc.,  have  co-operated  in 
the  fullest  degree  in  the  development  of  this  plan  of  campaign. 

Since  the  State  Sanatorium  at  Rutland  provides  ample  accom- 
modations for  all  incipient  cases,  no  special  provision  for  the 
treatment  of  this  class  has  been  made.  Our  efforts  have  thus  been 
directed  along  two  main  general  lines:  first,  the  protection  of  the 
well  against  infection ;  and  second,  the  care  of  the  various  classes 
of  advanced  consumptives.  The  work  undertaken  may  perhaps 
be  best  described  under  five  heads:  First.  Clinical.  Second.  Edu- 
cational. Third.  Social.  Fourth.  Sanit-ary.  Fifth.  Study  and 
investigation. 

I.     CLINICAL  WORK. 

Obviously  the  most  urgent  need  has  been  for  facilities  for  the 
care  of  the  advanced  cases,  and  the  first  efforts  of  the  trustees 
have  been  directed  toward  providing  such.  In  the  spring  of  1906 
the  trustees  purchased  an  estate  of  fifty-eight  acres  in  Mattapan, 
and  immediately  started  the  development  of  plans  for  a  municipal 
hospital  for  advanced  consumptives.  The  site  chosen  is  within 
city  limits,  in  a  quiet  suburb  approximately  seven  miles  from  the 


bo 
a 

2 
'3 


C  J  vj 


4 


LOCKE.  121 

center  of  the  city,  and  is  readily  accessible  by  trolley  from  any 
part  of  the  city.  The  land  is  admirably  adapted  for  the  develop- 
ment of  a  hospital  plant,  and  is  undoubtedly  the  most  favorable 
of  any  vacant  tract  situated  within  city  limits.  The  general 
hospital  scheme  as  planned  comprises  the  following  buildings: 
six  ward  buildings,  administration,  domestic  and  pathological 
buildings,  chapel,  laundry,  nurses'  home,  central  power  station, 
permanent  day-camp  and  a  group  of  cottage  wards ;  but  because 
of  the  lack  of  funds,  only  the  central  power  station,  two  ward 
pavilions,  the  day-camp,  one  cottage  ward  and  a  temporary  do- 
mestic building  can  at  present  be  built. 

The  administration  of  all  these  institutions,  as  well  as  the  Out- 
Patient  Department,  to  be  described  later,  is  in  charge  of  one 
executive  head,  and  the  medical  work  under  a  single  staff,  con- 
sisting of  a  Chief  of  Staff,  a  First  Assistant,  a  Visiting  Pathologist, 
a  Laryngologist  and  a  corps  of  Assistant  Physicians.  A  uniform 
system  in  the  keeping  of  clinical  records  will  be  installed  in  all 
departments,  and  by  a  simple  system  of  transfers  these  will  be 
cross-referenced. 

A.  Hospital  for  Advanced  Cases.  —  This  hospital  is  designed  to 
furnish  accommodations  for  the  care  of  consumptives  in  the  last 
stages  of  the  disease.  Although  this  class  represents  but  a  small 
percentage  of  all  consumptives,  the  building  of  this  hospital  is  of 
the  first  importance,  for  the  reason  that  they  are  the  class  most 
dangerous  to  the  community  and  the  type  most  needing  hospital 
care.  It  is  our  purpose  so  far  as  possible  to  permanently  detain 
all  cases  once  admitted  to  the  hospital. 

The  ward  buildings  are  of  the  two-story,  pavilion  type,  placed 
sixty-five  feet  apart,  connected  by  open  corridors,  and  are  so  placed 
as  to  permit  of  extension  by  the  addition  of  more  wards  to  the 
limit  of  four  hundred  beds.  Each  ward  building  is  to  cost  roughly 
$62,000,  and  will  contain  fifty-eight  beds.    They  are  of  fire-proof 


122  TUBERCULOSIS    IN    MASSACHUSETTS. 

construction  throughout,  two  stories  high,  and  are  arranged  with 
a  view  to  economy  and  efficiency  of  administration,  absolute 
cleanliness  and  comfort  for  the  patients.  Their  position  is  such 
as  to  afford  a  maximum  of  sunshine.  It  is  expected  that  these 
wards  will  be  completed  by  the  end  of  the  present  year,  and  the 
accommodations  which  they  will  aflford,  together  with  those  in  the 
various  institutions  in  the  city  which  receive  advanced  cases,  will, 
we  hope,  be  sufficient  for  all  destitute  cases. 

B.  The  Sanatorium  Day-camp.  —  German  statistics  show  that 
but  from  ten  to  fifteen  per  cent,  of  all  consumptives  are  of  the 
incipient  type,  and  those  in  the  most  advanced  stage  of  the  dis- 
ease probably  comprise  a  no  larger  percentage;  hence  the  greatest 
demand  is  constantly  felt  for  provisions  for  the  moderately  ad- 
vanced or  ambulatory  cases.  Experience  has  taught  us  that  the 
great  majority  of  consumptives  cannot  be  induced  to  enter  a 
hospital,  and,  even  were  it  possible,  the  expense  in  caring  for  so 
large  a  number  would  render  it  impossible  to  make  provisions  for 
them.  For  three  years  the  Boston  Association  for  the  Relief  and 
Control  of  Tuberculosis  has  successfully  maintained  a  sanatorium 
day-camp  for  consumptives  during  the  summer  months,  and  their 
success  in  this  special  work  has  led  us  to  attempt  the  same  thing 
on  a  larger  and  more  comprehensive  scale,  and  for  this  purpose 
we  have  erected  a  permanent  structure  immediately  adjacent  to 
the  main  hospital.  This  building,  which  was  opened  early  in  July, 
1908,  is  one  story  high,  one  hundred  and  fifty  feet  long,  thirty-six 
feet  wide,  of  rough  but  solid  wooden  construction,  and  unfinished 
on  the  inside.  Along  the  south  side  is  an  open  veranda  one  hun- 
dred by  sixteen  feet,  provided  with  an  overhanging  roof  of  eight 
feet  and  awnings.  The  building  contains  a  well-equipped  kitchen, 
capable  of  furnishing  food  for  a  maximum  of  five  hundred  patients 
a  large  storeroom  with  refrigerators,  a  patients'  dining-room  seat- 
ing one  hundred  and  eighty,  a  small  nurses'  dining-room,  two  rest 


Q 

O 
-J 

S^i^2S2o5g^CoS^< 

1 

i 


LOCKE.  123 

rooms  for  patients,  one  for  men  and  one  for  women,  a  thoroughly 
equipped  laboratory,  a  laryngological  room,  a  linen  room,  a  nurses' 
office,  a  medical  office  and  one  large  examining  room.  Steam  and 
electricity  are  to  be  furnished  from  the  central  power  station. 
Its  beautiful  situation  on  the  edge  of  a  small  grove  of  oaks  and 
sheltered  to  the  north  by  high  rocks  and  trees  gives  the  most  ideal 
opportunity  for  the  rest  treatment  for  patients.  At  least  two 
hundred  patients  can  be  accommodated  in  this  single  institution. 
The  routine  of  treatment  is  strictly  the  accepted  sanatorium  type. 
Patients  are  required  to  report  at  the  camp  at  nine  a.m.,  and  are 
allowed  to  return  to  their  homes  not  earlier  than  five  p.m.  or  later 
than  six  p.m. 

The  medical  work  is  in  charge  of  a  Director  and  an  Assistant, 
both  of  whom  are  assistant  physicians  to  the  Boston  Consumptives' 
Hospital.  At  least  one  of  these  assistants  is  required  to  be  in 
constant  attendance.  A  head  nurse  and  two  assistant  nurses  are 
also  assigned  to  the  work.  One  of  the  latter  will  devote  her  entire 
time  to  the  members  of  the  camp  in  their  homes,  and  especially 
to  the  following  up  of  delinquents.  The  same  exact  records  are 
to  be  kept  as  in  the  main  hospital.  As  a  routine,  the  patient  must 
first  be  registered  and  investigated  at  the  Out-Patient  Department 
before  admittance  to  the  camp. 

C  Cottage  IV ards.  —  Immediately  adjacent  to  the  day-camp  is 
being  erected  a  somewhat  different  type  of  building,  to  which  we 
have  given  the  name  of  "cottage  wards."  This  type  is  much  like 
the  "improved  lean-to's"  at  Liberty  and  other  sanatoria,  though 
of  somewhat  more  permanent  construction.  It  is  of  one  story, 
and  consists  of  a  central  portion  containing  a  large  assembly  room, 
two  locker-rooms,  two  shower-baths  and  one  tub-bath,  lavatories, 
a  wash-room,  an  emergency  ward  of  two  beds  and  a  nurses'  room. 
On  each  side  is  a  large  open  ward  sixty  by  eighteen  feet,  facing 
to  the  south,  the  floor  of  which  is  continuous  with  a  wide  veranda 


124  TUBERCULOSIS    IN    MASSACHUSETTS. 

on  the  south  side,  extending  the  entire  length.  The  front  of  each 
ward  is  closed  by  large  windows  of  three  sashes,  which  can  be 
raised,  thus  opening  the  entire  front  of  the  ward.  Likewise  along 
the  end  and  north  side  is  a  row  of  sliding  windows.  The  entire 
cottage  is  about  one  hundred  and  fifty  feet  long  and  provides  for 
twenty-six  beds.     The  estimated  cost  is  |8,ooo.  ■ 

Exactly  the  same  type  of  ambulatory  cases  will  be  treated  here 
as  in  the  day-camp,  and  precisely  the  same  hygienic-dietetic  regime 
will  be  followed.  It  is  designed  to  care  for  those  patients  without 
homes,  or  with  only  such  as  do  not  oflfer  proper  conditions  for  the 
patient  at  night.  Depending  upon  the  success  obtained  in  this 
form  of  treatment  and  the  demands  for  hospital  accommodations, 
it  is  the  purpose  of  the  Trustees  to  build  a  series  of  these  cottages 
about  the  day-camp  building  as  the  administrative  center.  In 
our  opinion,  no  form  of  home  treatment,  however  carefully  super- 
vised, can  give  as  good  results  as  can  be  obtained  with  this  method. 

D.  JVork  for  Patients.  —  The  plan  for  the  care  of  patients  in 
both  the  day-camp  and  cottage  wards  includes  provision  for  gradu- 
ated work.  This  will  be  made  possible  by  the  routine  daily  work 
to  be  done  in  the  institutions  and  on  the  farm  which  constitutes 
a  considerable  portion  of  the  estate.  We  have  in  mind  not  only 
to  prevent  the  patient  from  acquiring  habits  of  idleness  during  his 
treatment,  but  to  give  him  the  benefit  of  regular  occupation  of 
such  nature  and  length  of  time  each  day  as  his  condition  permits. 
In  other  words,  work  will  be  used  therapeutically. 

E.  The  Out-patient  Department  {Dispensary).  —  The  first  de- 
partment of  the  Consumptives'  Hospital  to  be  opened  was  the 
Out-Patient  Department,  the  first  clinic  day  being  September  ii, 
1907.  At  present  a  clinic  is  held  four  mornings  each  week,  Satur- 
day morning  being  reserved  for  children.  An  evening  clinic  will 
soon  be  opened.  The  place  of  the  dispensary  in  any  properly 
organized  municipal  tuberculosis  campaign  and  the  best  methods 


f 


I 


i 


LOCKE.  125 

to  be  employed  are  so  well  known  that  I  shall  not  dwell  upon 
these  subjects.  A  suitable  four-story  house,  centrally  located 
and  accessible  to  the  poorer  sections  of  the  city,  where  the  greatest 
number  of  cases  of  tuberculosis  are  found,  was  chosen,  thoroughly 
renovated  and  adapted  to  the  needs  of  a  tuberculosis  clinic.  In 
keeping  with  the  idea  of  Philip  and  others,  we  have  made  this 
clinic  the  center  of  all  activity,  as  will  be  seen  from  the  accompany- 
ing diagram.  This  diagram  is  designed  to  show  the  close  relation 
existing  between  our  Out-Patient  Department  and  all  other  in- 
stitutions receiving  tuberculosis  patients.  Those  under  our 
control  are  drawn  in  full  line,  those  under  other  control  but  still 
associated  with  our  work,  in  broken  line.  In  a  general  way,  the 
size  of  the  circle  is  intended  to  represent  the  relative  number  of 
cases  which  each  can  accommodate,  and  the  depth  of  line  the 
relative  importance  of  the  individual  factors.  All  cases  except 
the  few  bed  patients  must  first  be  registered  and  studied  at  the 
central  bureau,  then  assigned,  so  far  as  the  accommodations  will 
permit,  to  the  type  of  treatment  best  suited  to  the  stage  of  the 
disease,  the  social  and  financial  conditions  of  the  patient,  and  the 
individual.  The  double  arrows  indicate  that  cases  are  not  only 
sent  from  the  dispensary  to  various  other  institutions,  but  when 
discharged  from  these  are  referred  back  to  the  same  center.  In 
this  manner  a  permanent  record  will  be  kept  of  the  patients' 
whereabouts  and  condition.  I  am  convinced  that  this  close 
supervision  of  tuberculosis  patients  is  the  first  essential  to  suc- 
cessful control.  No  intelligent  efi"ective  work  in  controlling  the 
spread  of  the  disease  is  possible  without  it. 

A  list  of  all  cases  of  contagious  diseases  with  addresses  is  sent  to 
the  office  of  the  dispensary  daily  by  the  Board  of  Health. 

All  members  of  the  family  of  a  tuberculous  individual  are  sys- 
tematically sent  or  brought  to  the  clinic  for  examination.  This 
work  is  principally  done  by  the  visiting  nurses  from  our  clinic. 


126  TUBERCULOSIS    IN    MASSACHUSETTS. 

During  the  past  two  years  especially,  work  of  this  nature  has  been 
done  among  the  children  under  the  direction  of  the  committee 
from  the  Associated  Charities,  Boston  Association  for  the  Relief 
and  Control  of  Tuberculosis,  and  the  Boston  Consumptives'  Hos- 
pital. For  the  purpose  of  this  work  the  city  was  divided  into  four 
districts,  each  with  its  tuberculosis  clinic  to  which  the  children  of 
that  district  were  taken.  A  record  of  all  cases  was  sent  to  the 
Out-Patient  Department  of  the  Consumptives'  Hospital  as  a  cen- 
tral bureau.  In  consequence  of  the  better  facilities  for  the  work 
and  the  special  clinic  for  children  maintained  there,  the  majority 
of  the  children  have  been  sent  to  the  Out-Patient  Department. 
By  the  application  of  the  newer  exact  methods  of  diagnosis,  we 
have  found  a  surprising  number  of  children  to  be  infected. 

All  these  methods  above  mentioned  comprise  what  1  have 
termed  "aggressive  work."  Experience  has  convinced  us  that  by 
the  ordinary  methods  of  an  out-patient  department,  where  the 
patients  are  left  to  come  voluntarily,  only  a  small  percentage  of 
cases  is  ever  discovered.  A  considerable  portion  of  the  time  of 
our  nurses  is  spent  in  following  up  delinquents  and  in  bringing  in- 
dividuals to  the  clinic  for  examination. 

Besides  the  visiting  physician,  there  are  nine  nurses  on  duty  at 
the  dispensary,  four  of  whom  are  in  attendance  at  the  Out-Patient 
Department  on  clinic  morning.  The  routine  work  of  history  tak- 
ing, etc.,  is  done  by  these  nurses.  Besides  her  duties  at  the  clinic, 
each  of  the  nurses  is  assigned  a  definite  section  of  the  city,  and 
under  the  direction  of  a  Superintendent  of  Nurses  she  carries  out 
the  line  of  work  most  necessary.  Nothing  has  been  so  gratifying 
and  encouraging  to  us  as  the  success  which  these  nurses  have  at- 
tained in  their  work,  and  we  regard  them  more  and  more  as  the 
all-important  agents  in  the  work. 

In  spite  of  every  provision  for  suitable  institution  treatment 
and  the  exercise  of  every  possible  influence,  the  majority  of  con- 


at  yr]^JtcLfUi,m._ 


Cotk^lX^i^        -^U^^J^jr^  *y..WJw^ 


0/a*A^t<L,    I 


:mc 


I 


LOCKE. 


127 


sumptives  cannot  be  persuaded  to  leave  their  homes;  consequently, 
while  relying  on  the  hospital  system  now  being  developed  at  Mat- 
tapan  for  great  relief  by  caring  for  a  large  number  of  the  most  ad- 
vanced cases,  we  are  nevertheless  concentrating  every  effort  on 
the  work  with  the  patients  in  their  own  homes  done  under  the  con- 
trol of  the  dispensary.  The  cases  reported  to  the  dispensary  as 
too  sick  to  come  to  the  clinic  are  visited  in  their  homes  by  one  of 
the  dispensary  physicians,  or,  in  rare  instances,  by  one  of  the  city 
district  physicians.  As  a  rule,  these  are  at  once  removed  to  some 
hospital. 

A  small  lunch  room  has  been  fitted  up  in  the  basement  of  the 
Out-Patient  Department,  where  those  patients  desiring  it  are  given 
a  glass  of  milk.  Fourteen  quarts  are  dispensed  each  clinic  morn- 
ing. We  are  convinced  that  this  is  a  wise  proceeding,  especially 
with  the  children's  clinic. 

F.  Co-operation  with  the  State  Sanatorium  for  After-care.  — 
Arrangements  have  been  made  with  the  State  Sanatorium  at  Rut- 
land whereby  all  Boston  cases  discharged  who  were  originally  sent 
to  the  Sanatorium  by  the  Boston  Dispensary  shall  be  referred  back 
to  the  Boston  Dispensary,  and  all  others  to  the  Out-Patient  De- 
partment of  the  Consumptives'  Hospital.  During  the  year  1907 
three  hundred  and  eleven  cases  returned  to  Boston  from  the  State 
Sanatorium.  Through  the  Out-Patient  Department  we  are  now 
carrying  on  the  important  work  of  supervising  this  class  after  dis- 
charge from  the  sanatorium,  and  especially  seeking  to  fit  them  to 
take  up  some  occupation. 

G.  Special  Institutions  for  Children.  —  Thus  far  our  work 
among  children  has  been  restricted  largely  to  the  examination  of 
them  at  the  clinic  and  treatment  in  their  homes.  Several  plans  are 
now  being  considered  which  we  confidently  expect  will  soon  make 
it  possible  to  remove  many  from  the  unhygienic  home  surround- 
ings, at  least  temporarily,  to  those  which  are  more  ideal.    Ar- 


128  TUBERCULOSIS    IN    MASSACHUSETTS. 

rangements  have  already  been  made  with  the  Trustees  of  the 
Wellesley  Convalescent  Home  of  the  Children's  Hospital  at 
Wellesley,  and  .with  the  State  Hospital  School  for  Crippled 
Children,  at  Canton,  for  the  care  of  a  considerable  number 
of  the  early  or  suspected  children.  The  establishment  of  the 
Day-camp  for  Children,  at  Parker  Hill,  during  the  past  summer  by 
the  Boston  Association  for  the  Relief  and  Control  of  Tuberculosis 
has  greatly  increased  the  facilities  for  the  treatment  of  tuberculous 
children. 

2.     EDUCATIONAL    ACTIVITIES. 

Along  these  lines  perhaps  more  than  any  other  has  the  best 
work  been  accomplished  in  the  past  few  years,  and  with  the  relief 
from  clinical  work  which  our  hospital  has  given,  various  organiza- 
tions, such  as  the  Boston  Association  for  the  Relief  and  Control 
of  Tuberculosis,  have  found  it  possible  to  devote  themselves  more 
completely  to  the  field  of  education.  For  this  reason,  largely, 
our  hospital  has  considered  it  wise  to  participate  to  but  a  mod- 
erate degree  in  the  work  along  these  lines. 

September  15,  1906,  the  following  order  was  sent  by  the  Mayor 
to  all  heads  of  departments,  and  by  his  order  the  appended  regu- 
lations were  posted  in  all  municipal  buildings:  — 

MAYOR'S   ORDER. 
To  the  Heads  of  Departments. 

The  National  Association  for  the  Study  and  Prevention  of  Tuberculosis  recently 
adopted  the  following  resolution  and  sent  it  to  President  Roosevelt:  — 

"Resolved,  That  in  the  interest  of  Preventive  Medicine  and  the  cause  of  Indus- 
trial Hygiene  this  Association  respectfully  recommends  to  the  Chief  Executive 
of  the  Nation  the  desirability  of  instituting  an  inquiry  through  the  proper  officers 
of  the  government  as  to  the  sanitary  conditions  existing  in  all  government  offices 
and  workshops  where  a  large  number  of  persons  are  employed,  especially  with  a 
view  of  recommending,  if  necessary,  measures  for  the  prevention  of  tuberculosis 
therein." 

In  view  of  this  resolution,  and  in  the  interest  of  the  public  service,  1  hereby 
promulgate  the  following  order,  with  the  object  of  eliminating  and  preventing 
tuberculosis  among  the  employees  of  the  city  of  Boston:  — 


f 


LOCKE. 


129 


It  shall  be  the  duty  of  the  head  of  each  department  to  transmit  to  all  employees 
under  his  control  the  accompanying  rules  and  information  to  prevent  the  spread 
of  tuberculosis,  and  to  require  the  display  of  these  rules  in  such  manner  and  in 
such  number  as  is  necessary  to  carry  out  their  intent. 

It  is  hereby  required  of  each  department  to  ascertain  from  time  to  time  the 
names  of  persons  in  service  in  said  department  afflicted  with  tuberculosis,  and  to 
present  to  them  the  printed  rules  for  their  observance. 

The  non-observance  of  said  rules  shall,  in  the  discretion  of  the  head  of  the  de- 
partment, be  considered  a  just  cause  for  separation  from  the  service. 

Whenever  there  is  a  doubt  with  regard  to  any  person  in  the  city  service  as  to 
whether  said  person  is  afflicted  with  pulmonary  tuberculosis,  an  order  shall  be 
issued  by  the  head  of  the  department  for  said  person  to  present  himself  (or  her- 
self) at  one  of  the  city  hospitals  for  examination,  and  to  present  the  department 
a  certificate  from  the  superintendent  or  other  authorized  officer  of  the  said  hos- 
pital showing  the  result  of  said  examination. 

The  Board  of  Health  is  hereby  directed  to  cause  a  thorough  sanitary  inspection 
of  the  public  buildings  and  workshops  under  the  various  city  departments;  and 
said  Board  is  authorized  to  detail  from  its  respective  medical  services  a  Sanitary 
Board,  or  Boards,  for  this  purpose.  The  Sanitary  Board  thus  appointed  shall 
report  upon:  — 

First.  —  Unsanitary  conditions  immediately  remediable. 

Second.  —  Unsanitary  conditions  requiring  structural  changes. 

The  said  -Board  when  entering  upon  its  duties  in  any  department  shall  report 
to  the  executive  head  of  said  building  or  workshop,  who  shall,  on  the  request  of 
the  Board,  give  such  assistance  as  may  be  required. 

The  Sanitary  Board  shall  make  reports  to  the  Board  of  Health,  and  said  Board 
of  Health  shall  transmit  a  full  report  with  recommendations  to  the  Mayor. 

These  duties  to  be  additional  to,  and  not  to  take  precedence  of,  the  duties  of 
the  Board  of  Health  prescribed  by  ordinance. 

Regulations  to  prevent  the  Spread  of  Tuberculosis  in  Municipal  Build- 
ings, Offices  and  Workshops. 

1 .  All  employees  of  the  city  of  Boston  are  positively  forbidden  to  spit  upon  the 
floors. 

2.  Rooms,  hallways,  corridors  and  lavatories  shall  be  freely  aired  and  effectually 
cleaned  at  least  once  a  day,  and  not  during  working  hours. 

3.  Spittoons  shall  receive  a  daily  cleansing  with  very  hot  water,  and  when 
placed  ready  for  use  must  contain  a  small  quantity  of  water. 

4.  Dust  must  be  removed  as  completely  as  possible  by  means  of  dampened  cloths 
or  mops.  It  should  never  be  needlessly  stirred  up  by  a  broom  or  duster,  as  this 
practice  only  spreads  the  dust  and  germs. 

5.  Floors  of  tiling,  brick  or  stone  must  be  frequently  scoured  with  soap  and 
water. 


1^0  TUBERCULOSIS    IN    MASSACHUSETTS. 

6.  The  senior  clerks  in  charge  of  wortcrooms  shall  take  measures  to  secure  during 
working  hours  the  admission  of  as  much  fresh  air  and  sunshine  as  the  conditions 
will  permit. 

7.  The  use  of  individual  drinking  glasses  is  recommended. 

8.  Persons  in  the  employ  of  the  city  of  Boston  who  suffer  from  pulmonary 
tuberculosis  shall  be  separated  when  possible  from  others  while  at  work,  and  they 
should  be  cautioned  to  use  telephones  only  when  necessary. 

9.  Such  persons  will  not  be  permitted  to  use  the  public  spittoons,  but  must 
provide  themselves  with  individual  sputum  receivers,  preferably  of  easily  destruc- 
tible material,  and  carry  these  with  them  on  arrival  and  departure.  They  will 
be  held  strictly  responsible  for  the  disposal  and  destruction  of  their  own  sputum, 
so  that  no  other  person's  health  may  be  endangered  therefrom. 

10.  Such  persons  must  provide  their  own  drinking  glasses,  soap  and  towels, 
and  shall  not  use  those  provided  for  the  general  use. 

11.  Plainly  printed  notices,  reading  as  follows:  "  Do  not  spit  on  the  floor,  to 
do  so  may  spread  disease,"  shall  be  prominently  posted  in  rooms,  hallways,  cor- 
ridors and  lavatories  of  public  buildings. 

JOHN    F.  FITZGERALD, 

September  15,  1906.  Mayor. 

Circular  14. 

Subsequently  a  small  pamphlet,  entitled  "Tuberculosis,"  and 
containing  the  following  concise  chapters,  "The  nature  of  the  dis- 
ease," "Its  danger  and  sources  of  contagion,"  "How  to  prevent 
it,"  "  How  to  cure  it,"  and  "Advice  to  the  sick  and  the  well,"  was 
prepared  by  the  Trustees  and  mailed  to  every  voter  in  Boston. 

During  the  year  1907  two  hundred  large  posters,  eight  by  nine 
feet,  reading  as  follows:  — 

CONSUMPTIVES'    HOSPITAL    BULLETIN. 

SPITTING 

SPREADS 

DISEASE. 

POISONOUS  SPIT   DRIES   AND  GOES 

AS   DUST   INTO  OTHER   PEOPLE'S   LUNGS. 

CONSUMPTION 

IS   SPREAD 

IN   THIS   WAY. 

DON'T    BE   A 

CARELESS   SPITTER. 

TOBACCO  SPIT    IS   JUST   AS 

DANGEROUS   AS   ANY   OTHER. 


I 


ooNUiMpnvEr  hospital  bulletin  No.  I 


CONSUMPTION 

IS   CAUSED 
by  the    POISON    present    in    the 
Cooeumptive's   SPIT 


The  Poisonous  SPIT  DRIES  and 
goes  aa  DUST  into  other  people's 
Lungs 

DOITT  SPREAD  the  DISEASE, 
Don't  let  others  spread  it. 


DON'T  be  a  CARELESS  SPITTER 


CONSUMPTIVES 


SPITTING 

ON    THE 

FLOORS 


IS   A   MISDEMEANOR 
and   is   PUNISHABLE   BY  LAW 


s     a     DANGEROUS 
Disease  is  spread  in 


Spitting 
PRACTICE, 
that  way 

Protect  yourselves  and  others 
from  Disease  by  reporting  the 
CARELESS  SPITTER 


Don't  Spit  on  the  Sidewalks, 
where  people  may  get  the  Poison- 
ous Spit  on  their  clothing 

Don't    Spit    on     the     floors    of 

TROLLEY 
RAILWAY  CARS 

IT  MARRH  THE  DUST 
OF  THE  CARS  DANGEROUS 


SPIT   INTO  SPITTOONS, 
or  into  places  provided  for  spitting 


OOMSUMPTIVES'    HOSPITAL    BULLETIN 


CONSUMPTION 

and  other  Diseaees  are 

SPREAD  BY  CARELESS  SPIHINC. 


The  SPIT  of  Consumptives  is 
POISONOUS  because  it  is  full  of 
OERM8 

The  POISONOUS  SPIT  dries 
and  goes  as  DUST  into  other 
people's   LUN08 


U  yoa  breathe  the  dust  from 
Polaonooa  Spit  YOD  are  i.iabt.ib 
to  OET  DISEASE 


CONSUMPTIVES'   HOSPITAL   BULLETIN   I 


PEOPLE 
WHO  SPIT 

on    the  FLOOBS   of  their   Homes 
SPREAD  DISEASE. 


CONSUMPTION    especially    Is 
spread  in  thai  way 


Workmen  who  spit  on  the  floors 
of  their  Workshops  spread  disease 


TOBACCO  SPIT  is  just  as 
DANOEROUQ  as  any  OTHER 
SPIT 


OONSUMPnvEr    HOSPITAL   BULLETIN   I 


Don't  Spit  on  the  floors  of  your 
Rooms  or  Hallways. 

Don't  Spit  on  the  floors  of 
Public  Places— the  Spit  may  be 
POISONOUS 


Don't  Spit  on  the  floors  of  a  Shop 
or  Store.  Dried  Spit  in  the  form 
of  dOBt  Is  DANGEROUS 


SPIT  INTO 
SPITTDDN5 


BULLETINS    POSTED    BY    THE    BOSTON    CONSUMPTIVES'    HOSPITAL. 


I 


LOCKE. 


131 


were  displayed  free  of  charge  by  John  Donnelly  &  Sons,  bill  posters, 
on  bill  boards  in  various  sections  of  the  city. 

To  supplement  the  Board  of  Health  signs  and  with  the  consent 
of  the  health  authorities,  the  trustees  during  the  past  year  also 
issued  a  series  of  six  bulletins,  printed  on  yellow  metal  sheets 
similar  to  those  in  use  in  Yonkers,  ten  by  fourteen  inches.  These 
are  now  systematically  posted  in  all  railway  and  subway  stations, 
steamboat  wharves,  public  buildings,  many  of  the  freight  docks, 
and  in  lodging  and  tenement  houses.  Almost  daily  calls  are  re- 
ceived from  landlords  and  employers  for  these  bulletins. 

The  daily  papers  have  been  encouraged  and  aided  to  publish 
frequent  articles  and  editorials  regarding  some  general  topics  on 
the  subject  of  the  work  of  the  Consumptives'  Hospital. 

The  most  important  and  far-reaching  educational  work  has 
obviously  been  done  in  the  course  of  the  daily  visitation  of  con- 
sumptives in  their  homes  by  the  dispensary  nurses. 

3.     SOCIAL   WORK. 

BeHeving  the  tuberculosis  problem  to  be  more  social  than 
medical,  we  have  in  our  organization  sought  to  make  ample 
provision  for  this  phase  of  the  work.  The  conditions  under  which 
the  poor  live  are  of  as  much  if  not  even  greater  importance  than 
contagion  itself  in  determining  the  prevalence  of  the  disease, 
and  oifer  far  more  difficult  obstacles  to  be  overcome.  Upon  our 
nurses  who  have  the  supervision  of  the  patients  in  their  homes 
has  naturally  fallen  the  burden  of  the  social  investigation  and  the 
administration  of  relief.  The  present  Superintendent  of  Nurses, 
herself  a  trained  social  worker,  was  chosen  with  a  view  to  espe- 
cially directing  this  work.  Under  her  supervision  the  nurses 
are  given  a  systematic  training  along  social  lines  by  means  of 
regular  reading,  lectures,  conferences  and  personal  instruction. 
On  the  day  following  the  first  visit  to  the  dispensary,  each  patient 
is  visited  in  his  home  by  a  clinic  nurse,  and  a  thorough  investi- 


132  TUBERCULOSIS    IN    MASSACHUSETTS. 

gation  is  made  of  the  social  and  financial  conditions.  A  report 
of  these  investigations  on  a  printed  form  is  filed  with  the  clinical 
history. 

We  have  constantly  sought  aid  and  counsel  of  the  Associated 
Charities.  Their  valuable  records  are  always  open  to  us,  and 
assistance  to  patients  is  seldom  given  except  after  the  most 
thorough  investigation  by  this  organization  and  with  their  advice. 
If,  after  conference  with  the  Superintendent  of  Nurses  and  the 
Director  of  the  clinic,  it  seems  necessary  to  give  relief,  a  confer- 
ence is  held  with  the  representative  of  the  Associated  Charities 
and  the  case  further  investigated  by  them.  Each  week  the  nurses 
attend  the  conference  of  the  workers  in  the  Associated  Charities 
for  their  particular  district.  One  of  the  first  duties  of  the  nurse 
is  to  become  familiar  with  the  various  charitable  organizations, 
societies,  churches,  etc.,  in  her  particular  district,  to  whom  she 
can  turn  for  assistance. 

After  careful  consideration,  we  have  settled  upon  the  policy  of 
seeking  as  far  as  possible  to  give  relief  through  already  existing 
channels,  for  we  believe  it  can  thus  be  done  more  wisely  and 
economically  than  through  a  special  department  of  our  own.  In 
only  one  respect  have  we  departed  from  this  principle.  The 
Consumptives'  Hospital  has  undertaken  the  dispensing  of  milk 
to  needy  cases  free  of  charge,  the  expense  of  this  charity  being 
met  from  our  fund  for  maintenance.  For  the  past  few  months 
the  amount  dispensed  gratis  in  this  way  has  been  about  eight 
thousand  quarts  per  month.  In  spite  of  the  enormous  scale  on 
which  this  particular  form  of  relief  is  carried  on,  investigations 
by  the  Associated  Charities  of  our  list  of  cases  receiving  it  indicate 
that  but  an  insignificant  part  has  been  unwisely  given. 

Our  dispensary  is  soon  to  benefit  by  the  services  of  an  expert 
social  worker,  who  shall  give  her  entire  time  to  the  study  of  various 
social  problems  arising  in  our  work. 


LOCKE,  133 

In  every  way  possible  we  have  striven  to  stimulate  all  efforts 
to  improve  the  dwellings  of  the  poor,  the  workshops,  etc.,  which 
have  such  an  important  bearing  on  the  spread  of  tuberculosis. 

4.  SANITARY  SURVEILLANCE  THROUGH   THE  BOARD   OF 

HEALTH. 

Realizing  that  success  must  ultimately  depend  upon  the 
thoroughness  and  efficiency  with  which  sanitary  surveillance  is 
carried  out,  the  Consumptives'  Hospital,  though  organized  as 
an  independent  department,  is  working  in  the  closest  accord 
with  the  Health  Department  of  the  city  of  Boston.  The  Board 
of  Health  is  conducting  effective  work  along  the  following 
lines:  — 

1.  Inspection  and  registration  of  all  cases  of  tuberculosis  is 
compulsory. 

2.  Medical  inspection  of  all  reported  cases  is  systematically 
carried  out. 

3.  Obligatory  free  disinfection  is  done  after  the  death  or  re- 
moval of  every  consumptive. 

4.  Promiscuous  spitting  is  prohibited,  and  signs  to  that  effect 
and  calling  attention  to  the  penalty  for  violation  of  this  law  are 
posted  by  the  Board  of  Health  in  all  public  places. 

5.  A  bacteriological  laboratory  is  maintained  for  the  free 
examination  of  sputa,  throat  cultures,  etc.  During  1906,  23,850 
examinations  were  made,  of  which  3,602  were  for  tuberculosis. 

6.  An  excellent  system  of  inspection  of  schools  and  school 
children  is  in  force.  This  work  is  done  by  eighty  physicians 
regularly  appointed  as  inspectors  of  schools,  and  twenty  school 
nurses. 

7.  The  health  authorities  are  given  power  to  forcibly  remove 
and  detain  in  a  hospital  any  case  of  tuberculosis  deemed  dangerous 
to  the  community. 


134  TUBERCULOSIS    IN    MASSACHUSETTS. 

5.     STUDY   AND    INVESTIGATION. 

Many  questions  still  remain  to  be  studied,  especially  along  the 
lines  of  the  best  methods  of  municipal  control,  and  these,  together 
with  the  study  of  clinical  and  laboratory  problems,  are  included 
in  our  program.  We  believe  that  the  study  of  scientific  problems 
of  this  particular  nature,  of  the  best  methods  suited  to  their  suc- 
cessful solution  and  of  our  results  obtained  should  go  hand  in 
hand  with  pure  clinical  work.  The  municipality  should  as 
properly  furnish  funds  for  these  investigations  and  for  the  estab- 
lishment and  maintenance  of  laboratories  as  for  the  care  of 
patients. 

Unfortunately,  the  necessity  for  stimulation  to  better  instruc- 
tion in  our  medical  schools  is  daily  apparent,  and  we  are  accord- 
ingly placing  our  clinical  material  at  the  disposal  of  clinical 
teachers. 


I 


STONE  —  KREUSI.  135 


CHAPTER    XL 

THE  WORK  OF   THE  ANTI  TUBERCULOSIS  SOCIETIES  IN  THE 

STATE. 

Arthur  K.  Stone,  M.D.,  and  Walter  E.  Kreusi,  B.S. 

The  development  of  a  public  sentiment  in  favor  of  a  general 
effort  to  control  tuberculosis  has  been  very  different  in  the  various 
communities  throughout  the  State.  In  many  cases  the  work  has 
originated  in  the  persistent  preaching  of  some  prophet  who  has 
talked  in  season  and  out  of  season  upon  the  importance  of  this 
subject.  Sometimes  this  individual  has  been  a  physician,  some- 
times a  layman.  Several  of  the  most  important  steps  which  have 
been  taken  by  the  legislative  bodies  of  the  State  and  in  the  munici- 
palities have  been  started  by  public-spirited,  far-sighted  politi- 
cians, apparently  unsupported  by  any  public  sentiment.  In 
some  instances  the  local  board  of  health  has  been  active  and  per- 
sistent, until  at  last  it  has  aroused  a  public  sentiment  which  would 
support  it  in  its  plans  for  the  protection  of  the  public.  In  still 
other  cases  groups  of  private  citizens  have  met  and  devised  ways 
and  means  to  insure  the  enforcement  of  the  existing  laws  by 
their  local  boards  of  health  or  other  municipal  executives. 

Dr.  A.  T.  Cabot,  when  president  of  the  Massachusetts  Medical 
'  Society,  devoted  much  time  to  arousing  the  local  medical  societies 
to  the  importance  of  the  tuberculosis  problem.  Recently  the 
initiative  in  the  tuberculosis  campaign  has  come  from  the  Asso- 
ciated Committees  of  the  Massachusetts  Medical  Society  organized 
through  his  efforts.  This  work  among  the  members  of  the  medical 
profession  has  been  of  great  value,  because  the  public  was  becom- 
ing better  educated  in  regard  to  the  subject  of  tuberculosis  than 
were  the  natural  leaders,  the  physicians.  _^ 


136  TUBERCULOSIS    IN    MASSACHUSETTS. 

Very  frequently  some  public-spirited  individual,  seeing  the 
importance  of  the  movement,  has  arranged  for  an  exhibit  or  lec- 
ture, and  paid  all  expenses,  hoping  thereby  to  arouse  public 
interest.  In  still  other  instances  the  Social  Service  Department 
of  the  Massachusetts  General  Hospital  has  called  the  attention 
of  the  charity  workers  of  various  communities  to  their  need  of 
organization  by  the  repeated  reference  to  these  charity  workers 
of  cases  of  tuberculosis  for  which  it  was  the  duty  of  the  town  or 
city  to  provide. 

In  whatever  manner  the  enthusiasm  for  the  tuberculosis  work 
has  been  aroused,  it  has  almost  always  crystalized  itself  into  the 
formation  of  a  new  association,  whose  sole  function  it  is  to  deal 
with  this  particular  problem,  or  in  a  few  instances  in  the  forma- 
tion of  a  special  committee  or  a  pre-existing  charity  organization 
or  district  nursing  association. 

The  comprehensiveness  and  precise  nature  of  the  work  of  the 
new  association  has  naturally  varied  within  wide  limits,  depend- 
ing on  many  factors,  but  chiefly  on,  first,  the  existing  conditions 
in  the  community  relative  to  the  number  of  cases,  etc.,  and  sec- 
ond, the  type  and  extent  of  the  work  and  the  activity  of  the  city 
or  town  officials.  Naturally  in  those  localities  where  provisions 
have  been  made  by  the  community  for  the  care  of  the  sick  and 
for  adequate  sanitary  surveillance,  the  activities  of  these  voluntary 
societies  have  been  largely  along  the  various  lines  of  education 
and  relief.  Where  no  provision  has  been  made,  the  functions 
of  the  associations  have  extended  over  practically  the  whole  field, 
and  may  be  roughly  grouped  to  include  the  following :  — 

1.  Education. 

2.  Co-operating  with  town  or  city  authorities  to  carry  out  laws 
and  ordinances. 

3.  Promoting  legislation. 

4.  Registration  of  cases. 


STONE  —  KREUSI.  I37 

5.  Maintenance  of  clinics,  day-camps  and  classes. 

6.  Home  supervision  through  visiting  nurses  or  voluntary 
visitors. 

7.  Relief  in  the  homes. 

8.  Systematic  examination  of  members  of  the  families  of  con- 
sumptives. 

9.  Furnishing  funds  for  the  treatment  of  the  consumptives  in 
institutions  or  in  proper  surroundings. 

ID.  Seeking  suitable  employment  for  consumptive  working- 
men. 

Besides  the  strictly  anti-tuberculosis  societies,  many  others, 
such  as  the  district  nursing  associations,  church  societies,  women's 
clubs,  labor  unions  and  various  charitable  organizations,  have 
contributed  much  to  the  movement,  chiefly,  however,  in  educating 
the  public  and  providing  relief.  In  this  chapter,  however,  only 
those  associations  or  committees  which  have  been  formed  for  the 
specific  purpose  of  combating  tuberculosis  will  be  considered. 

The  general  idea  of  the  place  in  the  community  which  such  an 
association  should  occupy  can  be  best  presented  by  a  somewhat 
careful  study  of  the  problems  that  have  confronted  the  pioneer 
association,  the  Boston  Association  for  the  Relief  and  Control  of 
Tuberculosis,  since  its  organization  five  years  ago,  as  it  has  fur- 
nished the  model  for  all  other  similar  organizations  in  the  State. 

The  Boston  Association  for  the  Relief  and  Control  of  Tubercu- 
losis was  founded  in  1903  and  incorporated  in  1905.  This  organi- 
zation had  its  origin  in  a  self-appointed  committee,  which  had  been 
specially  active  in  the  winter  of  1900-01,  and  had  had  much  to  do 
with  the  movement  which  led  to  the  appropriation  of  |i  50,000  by 
the  city  of  Boston  for  a  Municipal  Hospital  for  Consumptives. 
Mayor  Hart  gave  his  thorough  approval  to  the  movement.  The 
original  order  was  introduced  into  the  City  Council  by  Mr.  OToole 
of  South  Boston. 


138  TUBERCULOSIS    IN    MASSACHUSETTS. 

The  advent  of  Mayor  Collins,  however,  brought  the  progress 
of  the  development  of  a  new  hospital  to  a  standstill,  for  the  reason 
that  he  considered  the  surn  inadequate  to  the  purpose.  The 
committee  continued  to  meet  to  discuss  the  tuberculosis  prob- 
lems of  the  city.  It  was  composed  of  members  from  the  medical 
profession,  the  Associated  Charities,  the  Instructive  District 
Nursing  Association,  the  Women's  Educational  Union  and  the 
Massachusetts  Emergency  and  Hygiene  Association.  It  was 
early  recognized  by  some  of  the  workers  that  the  field  was  so 
large  that  in  spite  of  the  many  societies  for  special  objects  already 
in  the  city  there  was  need  of  a  new  society  which  should  devote 
its  energies  exclusively  to  the  tuberculosis  problems,  as  it  was 
evident  that  none  of  the  existing  societies  could  take  on  the  new 
work,  which  was  assuming  large  proportions. 

The  active  work  of  the  Association  is  determined  by  an  Execu- 
tive Committee  of  ten,  consisting  of  the  officers  and  six  additional 
members.  The  committee  meets  every  two  weeks  through  the 
greater  part  of  the  year.  Matters  of  general  policy  are  discussed 
at  council  meetings  held  from  time  to  time  through  the  winter. 
The  council  has  fifty  members,  and  in  its  membership  are  included 
many  of  the  best-known  citizens  of  the  city. 

The  permanent  committees  having  the  active  direction  of 
the  many  lines  of  work  number  five,  and  are:  Executive  Commit- 
tee, Finance  Committee,  Committee  on  Education  and  Hos- 
pitals, Committee  on  Relief  and  Control,  Committee  on  Day- 
Camp. 

A  salaried  secretary  devotes  his  entire  time  to  the  immediate 
direction  of  the  work,  and  a  nurse  is  also  constantly  em- 
ployed. 

Financial  support  is  derived  entirely  from  voluntary  contri- 
butions and  the  annual  dues  from  its  nine  hundred  members. 
The  gross  disbursements  by  years  are  as  follows:  — 


STONE  —  KREUSI 


1904, 
1905, 
1906, 
1907, 


139 

$4415  57 

9,959  10 

12,754  65 

18,697  21 


nd  in  the  State,  the  Boston 


As  the  first  association  of  its  ki 
Association  has  done  much  to  arouse  pubHc  sentiment  through- 
out the  Commonwealth  to  an  appreciation  of  the  importance 
of  the  tuberculosis  work.  Previous  to  its  formation  even  the 
Massachusetts  Medical  Society  had  taken  no  action  on  this  im- 
portant subject.  Therefore,  much  of  its  early  work  was  devoted 
to  arousing  the  officials  of  the  city  and  State  to  recognize  the 
existing  needs.  This  dealing  with  the  legislators,  both  state 
and  municipal,  and  with  the  boards  of  health,  boards  of  hospital 
trustees  and  charity  organizations,  both  in  and  out  of  the  city, 
has  required  much  tact  and  thorough  appreciation  of  the  general 
problem  on  the  part  of  the  secretaries  and  other  members  of  the 
Association  who  have  been  called  upon  to  do  this  work.  While 
the  entire  credit  for  the  results  which  have  ensued  by  the  above 
work  cannot  be  given  to  the  Boston  Association,  yet  in  a  large 
measure  many  of  the  steps  in  advance  made  have  been  taken  as 
the  result  of  its  efforts.  Among  the  most  important  of  its  achieve- 
ments is  the  aid  which  it  has  given  in  bringing  about  the  organi- 
zation of  the  Boston  Consumptives'  Hospital  and  its  comprehen- 
sive plan  of  work.  Several  of  the  measures  passed  by  the  State 
Legislature  were  proposed  by  the  Association,  and  in  all  instances 
its  influence  has  been  freely  given  in  support  of  worthy  legis- 
lative bills  dealing  with  the  tuberculosis  problem. 

The  Boston  Board  of  Health  already  occupied  an  advanced 
stand  on  many  of  the  positions  necessary  for  the  fight  against 
tuberculosis  when  the  Boston  Association  came  into  existence. 
A  municipal  laboratory  was  in  operation,  and  free  examination 


140  TUBERCULOSIS    IN    MASSACHUSETTS. 

of  sputum  was  made.  Tuberculosis  was  recognized  as  a  con- 
tagious disease,  and,  although  registration  was  required,  it  was 
not,  nor  is  it  to-day,  sufficiently  enforced.  Hence  the  registra- 
tion which  has  been  attempted  is  still  imperfect.  The  recog- 
nition of  tuberculosis  as  a  disease  dangerous  to  the  public  was 
carried  to  its  logical  conclusion  by  the  Boston  Board  of  Health 
before  1901  by  the  forcible  removal  of  uncleanly  and  dangerous 
patients  to  the  Municipal  Hospital  on  Long  Island.  So  far  as  is 
known,  this  was  the  first  board  of  health  in  the  world  to  take  such 
action.  A  system  of  school  inspection  had  also  been  instituted, 
and  many  important  ordinances  passed  by  the  city  government. 
In  many  instances  public  opinion  did  not  support  these  measures, 
but  so  far  as  has  been  possible  from  the  funds  at  the  disposal  of 
the  Board,  and  when  not  restrained  by  adverse  executive  action 
on  the  part  of  the  mayors,  the  Board  have  given  steady  support 
to  the  enforcement  of  the  ordinances,  as  their  attention  has  been 
directed  from  time  to  time  to  flagrant  infractions  of  the  same. 
There  has  resulted  a  general  strengthening  of  the  power  given 
various  city  officials  in  consequence  of  the  action  of  the  Associa- 
tion in  constantly  urging  them  to  greater  vigilance  and  co-opera- 
tion. 

The  same  general  statements  apply  to  the  State  Board  of 
Health  regarding  its  interest  and  co-operation  in  the  organized 
effort  against  tuberculosis. 

For  the  past  two  years  the  local  provisions,  through  clinics,  day- 
camps  and  hospitals,  for  the  care  of  the  consumptive  poor,  have 
increased  rapidly,  very  largely,  we  believe,  as  a  result  of  the  in- 
formation in  regard  to  the  pressing  needs  of  the  community  and 
the  supporting  public  sentiment  that  has  been  aroused  by  the 
work  of  this  Association. 

In  the  beginning,  a  campaign  of  education  was  inaugurated. 
The  Central  Labor  Union  of  Boston  was  addressed,  and  its  co- 


i 


STONE  —  KREUSI,  I4I 

operation  secured  in  arranging  for  lectures  before  individual 
labor  unions.  During  the  first  year  alone  (1903-04)  10,500  people 
attended  the  eighty-two  lectures  given  before  these  unions. 
These  lectures  were  delivered  by  physicians  active  in  the  cause, 
and  were  in  many  instances  illustrated  by  stereopticon  demon- 
strations. A  series  of  lectures  was  given  in  the  Roman  Catholic 
churches  during  Lent,  the  first  lecture  being  in  the  Cathedral. 
These  lectures  had  the  special  sanction  of  the  Archbishop,  and 
large  audiences  were  secured.  In  addition,  lectures  were  also 
given  wherever  audiences  could  be  secured,  in  all  several  hundred 
being  held,  which  were  attended  by  nearly  one  hundred  thousand 
persons. 

Several  hundred  thousand  pamphlets  and  circulars,  among 
them  "A  War  Upon  Consumption,"  "Friendly  Advice  to  Con- 
sumptives," "Protecting  the  Healthy  from  Tuberculosis,"  "Com- 
bating the  Great  White  Plague,"  "The  Modern  Crusade  Against 
Consumption,"  and  other  special  publications,  have  been  dis- 
tributed. Assistance  has  been  freely  given  in  the  preparation 
of  various  other  circulars  which  have  been  distributed  by  other 
societies  and  by  the  municipality.  Many  thousand  placards 
have  been  furnished  employers  for  display  in  their  factories  and 
workshops. 

One  of  the  most  effective  ways  of  reaching  the  public  is  through 
the  daily  newspapers,  and  these,  in  Boston  especially,  have 
generously  co-operated  in  the  educational  work  by  the  frequent 
publication  of  material  furnished  by  the  secretary  of  the  Associa- 
tion; and  their  active  support  of  the  day-camp  and  other  enter- 
prises of  the  Association  has  been  of  most  material  assistance. 

In  1904  a  small  exhibit  was  made  by  the  Association  at  a  fair 
which  was  held  at  Mechanics  Hall.  The  tents  and  various  methods 
of  out-door  life  attracted  so  much  attention  and  the  people  seemed 
so  eager  for  information  about  tuberculosis  that  it  was  deemed 


142  TUBERCULOSIS    IN    MASSACHUSETTS. 

advisable  that  a  larger  and  more  complete  exhibition  should  be 
held.  The  Boston  Association  thereupon  petitioned  the  General 
Court  that  an  appropriation  should  be  made  for  the  State  to  hold 
an  exhibit  under  the  auspices  of  its  Board  of  Health  for  the  gen- 
eral instruction  of  the  people.  The  State  Board  of  Health  readily 
adopted  the  idea,  and  held  a  most  successful  exhibit  in  January 
of  1906,  with  a  total  attendance  of  about  twenty-six  thousand 
persons.  Meantime  the  small  exhibit  of  the  Association  had 
been  travelling  about  the  country  doing  missionary  work,  going 
to  Springfield,  Mass.,  to  Concord  and  Manchester,  N.  H.,  Bur- 
lington, Vt.,  Newport,  R.  I.,  New  Haven,  Meriden  and  Waterbury, 
Conn.,  and  finally  to  Scranton,  Pa. 

Immediately  after  the  close  of  the  State  Tuberculosis  Exhibition 
a  compact  travelling  exhibit,  arranged  to  demonstrate  in  a  practi- 
cal manner  facts  regarding  the  nature  of  tuberculosis,  its  mode 
of  spread,  and  the  best  methods  of  prevention  and  treatment, 
and  consisting  of  maps,  charts,  models  of  tents,  shacks  and  sana- 
toria buildings,  photographs  and  stereopticon  slides,  was  prepared. 
In  many  instances  the  materials  were  the  same  or  duplicates  of  the 
State  Board  of  Health's  exhibit.  This  has  been  shown  in  many 
different  wards  of  the  city,  where  it  has  been  visited  by  the  school 
children  of  certain  grades  under  the  escort  and  direction  of  their 
teachers.  When  not  in  use  in  Boston  the  exhibit  has  visited  no 
less  than  thirty-seven  other  cities  and  towns  in  Massachusetts. 
Four  times  it  has  passed  beyond  the  state  limits,  i.e.,  to  Provi- 
dence, R.  1.,  Pittsburg,  Pa.,  Manchester,  N.  H.,  and  Syracuse, 
N.  Y.  In  each  case  the  exhibit  was  continued  from  a  few  days 
to  a  week,  and  was  supplemented  daily  by  lectures  on  some  im- 
portant phase  of  the  subject.  In  all  nearly  one  hundred  thousand 
persons  have  seen  it.  The  direct  fruits  of  the  exhibit  are  shown 
by  the  subsequent  formation  of  associations  in  many  of  the  towns 
to  which  it  has  been  sent. 


STONE  —  KREUSI.  I43 

The  co-ordination  of  the  work  of  all  societies  which  can  in  any 
way  contribute  to  the  general  organization  has  always  been  one 
of  the  chief  aims  of  the  Boston  Association.  Through  its  direc- 
tion many  of  these  have  given  valuable  assistance,  and  the  co- 
operation of  all  in  their  varied  lines  has  made  it  possible  to  cover 
with  considerable  success  the  whole  field  of  the  work. 

Co-operation  represents  the  method  by  which  much  of  the  relief 
work  is  carried  on.  Either  by  this  means  or  directly  through  the 
funds  of  the  society,  many  patients  have  been  aided  to  enter 
the  institution  best  suited  to  their  needs,  and  in  many  cases  the 
patients'  family  has  been  provided  for.  Where  it  has  been  neces- 
sary for  the  patient  to  receive  care  in  his  own  home,  the  proper 
aid  has  been  given.  Direct  supervision  of  this  branch  is  in  the 
hands  of  a  visiting  nurse  who  is  permanently  in  the  employ  of  the 
Association.  She  is  detailed  to  attend  the  examining  clinic  of 
the  State  Sanatorium,  where  she  sees  all  applicants,  advising  those 
who  are  accepted  regarding  necessary  preparations  and  equipment, 
and  especially  getting  in  touch  with  the  two-thirds  of  the  appli- 
cants who  are  rejected.  During  the  year  1907  the  visiting  nurse 
made  1,443  visits  and  interviewed  and  assisted  1,493  persons.  In 
spite  of  the  comprehensive  program  now  carried  out  by  various 
agencies  in  the  city,  the  Association  nurses  still  find  much  to  do 
in  investigating  and  in  visiting  cases  which  as  yet  have  not  come 
under  the  care  of  any  special  society  or  clinic.  The  different 
forms  of  relief  are  too  numerous  to  enumerate  here,  but  the  fol- 
lowing summary  of  the  disposition  of  six  hundred  and  thirty-three 
cases  for  a  single  year  will  suggest  its  scope:  — 

Disposition  of  cases  reported :  — 
Gave  instruction  and  advice  to,       .  .  .         .281 

Aided  in  securing  admission  to  the  State  Sanatorium  at  Rutland,  .        44 

Aided  in  securing  admission  to  the  Sharon  Sanatorium,     ....  2 

Aided  in  securing  admission  to  hospitals  and  homes  for  advanced  consump- 
tives,       ........••••         22 


144  TUBERCULOSIS    IN    MASSACHUSETTS. 

Aided  in  securing  admission  to  public  institutions,    .....  21 

Sent  to  the  day-camp  at  Mattapan, 58 

Referred  to  the  District  Nursing  Association  for  continued  nursing  at  home,  .  52 

Referred  to  various  private  charities  for  relief,           .....  63 

Referred   to   the  Board  of  Health  for  removal,  or    for  the  correction  of 

sanitary  abuses,         ..........  38 

Wrong  addresses,  moved,  etc.,         ........  52 


Total  number  reported,   .........       633 

Until  the  responsibility  was  assumed  by  the  Boston  Consump- 
tives' Hospital  and  the  Boston  Dispensary,  the  visiting  nurse  also 
had  supervision  over  all  Boston  cases  discharged  from  the  State 
Sanatorium. 

It  has  been  the  established  policy  of  the  Association  to  undertake 
any  new  piece  of  work  which  seems  pressing,  and  to  carry  it  for- 
ward until  it  is  demonstrated  that  the  work  is  necessary,  then 
other  societies  or  the  municipality  are  usually  found  ready  to 
carry  it  on,  and  the  Association  immediately  withdraws  and  seeks 
other  fields  of  usefulness.  In  accordance  with  this  policy,  it  has 
undertaken  a  number  of  investigations  into  the  condition  of  various 
groups  of  persons  afflicted  with  tuberculosis,  or  into  special  con- 
ditions existing  in  certain  sections  of  the  city  or  in  certain  trades 
and  workshops,  or  into  the  conduct  of  certain  institutions.  The 
results  of  these  investigations  have  been  frequently  shown  to  the 
persons  only  who  are  able  to  correct  abuses  that  were  found,  or 
to  help  improve  institutions  already  doing  excellent  work. 

A  central  registration  bureau  was  early  organized,  and  has  been 
maintained  up  to  the  present  time.  All  known  cases  of  tubercu- 
losis are  regularly  referred  to  the  Association  by  the  Board  of 
Health  and  the  various  tuberculosis  clinics,  and  from  these  all 
possible  information  is  recorded  regarding  the  patient  and  particu- 
larly his  whereabouts  and  the  special  measures  which  have  been 
taken  for  his  relief.  The  catalogue  now  includes  nearly  ten  thou- 
sand cases. 


CHILDREN'S    DAY  CAMP    AT    PARKER    HILL.      Maintained    by    the 

Boston   Association. 


STONE  —  KREUSI.  I45 

Much  has  been  done  in  the  systematic  investigation  of  the  chil- 
dren of  tuberculous  families,  and  in  studying  the  social  and  home 
conditions  of  the  tuberculous  generally. 

The  Association  organized,  in  the  spring  of  the  present  year, 
experimental  classes  for  school  children  having  tuberculosis,  or 
who  are  especially  exposed  to  infection.  Its  purpose  has  been  to 
teach  home  and  personal  hygiene,  cooking  for  the  sick,  and  the 
practical  use  of  out-of-door  exercise  to  children  who  particularly 
stand  in  need  of  such  knowledge.  The  work  has  been  popular 
with  the  children,  and  permission  to  attend  the  classes  has  been 
eagerly  sought. 

To  obtain  suitable  employment  for  the  cases  that  have  been 
discharged  as  arrested  from  the  various  clinics  is  a  very  perplexing 
problem.  Much  effort  has  been  expended  by  the  staff  of  the 
Association  upon  individual  cases.  Recently  a  committee  repre- 
senting various  organizations  has  been  assembled  to  consider  what 
may  be  done  to  meet  this  pressing  need. 

In  1905  the  first  sanatorium  day-camp  for  consumptives  in 
America  was  started  by  the  Association  through  the  persistent 
effort  of  its  secretary,  Mr.  A.  M.  Wilson.  For  two  years  the  camp 
was  held  on  the  grounds  of  the  Robert  Brigham  Hospital  on  Parker 
Hill,  and  in  1907  on  the  grounds  of  the  Boston  Consumptives  Hos- 
pital at  Mattapan.  The  daily  cost  per  patient  was  diminished 
each  year,  being  as  follows:  for  1905,  83  cents;  for  1906,  60  cents; 
and  for  1907,  52  cents.  The  total  expense  of  the  camp  during  the 
three  years  amounted  to  over  1 18,000.  The  Association  so  com- 
pletely demonstrated  the  absolute  need  of  the  camp  as  a  factor 
in  the  care  of  consumptives  in  a  city,  that  the  Municipal  Hospital 
has  undertaken  to  carry  on  the  work  as  a  permanent  part  of  its 
institution.  The  day-camp  idea  has  also  been  adopted  by  many 
other  localities. 

During  the  present  season  the  .Association  is  maintaining  a  day- 
camp  for  children  on  Parker  Hill. 


146  TUBERCULOSIS    IN    MASSACHUSETTS. 

Such  in  brief  is  an  outline  of  the  activities  of  the  Boston  Associa- 
tion for  the  ReHef  and  Control  of  Tuberculosis.  Many  and  per- 
plexing questions  have  been  presented  to  the  attention  of  the 
Executive  Committee,  unwise  enthusiasm  has  at  times  been 
checked  and  greater  enthusiasm  and  zeal  at  other  times  developed. 
The  evils  attendant  on  the  movement  have  been  met  as  far  as 
possible.  Public  nominations  at  times  have  been  made  at  the 
request  of  officials  and  at  other  times  insisted  upon  to  officials. 
The  work  has  been  varied  but  continuous,  and  practical  encour- 
agement has  been  held  out  to  almost  every  real  worker  in  the 
cause. 

Many  communities  have  district  nursing  associations,  efficient 
women's  clubs  and  other  methods  of  caring  for  the  sick  and  needy 
of  the  town  or  city,  and  are  doing  much  good  work,  as  stated 
above;  but  the  following  list  of  cities  and  towns  have  distinct 
organizations  or  special  committees  for  the  tuberculosis  work:  — 

I 

ANDOVER. 

The  Andover  Tuberculosis  Committee;  organized  in  1908. 
President,  Mr.  A.  E.  Stearns;  Secretary,  Miss  A.  P.  Hincks, 
183  Main  Street. 

The  principal  work  so  far  accomplished  has  been  a  series  of 
lectures  upon  tuberculosis,  for  the  purpose  of  arousing  public 
sentiment  and  raising  money  for  a  visiting  nurse.  £ 

Cases  of  tuberculosis,  known  to  the  physicians  of  the  town  as 
needing  assistance,  are  referred  to  the  committee,  and  are  then 
seen  in  their  homes  by  the  nurse  or  volunteer  visitors.  Relief 
work  is  carried  out  by  the  Andover  Guild.  The  town  helps 
worthy  cases  to  go  to  Rutland,  and  the  Board  of  Health  co- 
operates with  the  committee  in  its  disinfection  work.  It  is  in- 
tended to  develop  the  relief  work  and  to  extend  the  educational 
work  by  further  lectures  upon  subjects  of  general  hygiene  as  well 
as  tuberculosis.  s. 

I 


STONE  —  KREUSI.  I47 

BOSTON. 

The  Boston  Association  for  the  ReHef  and  Control  of  Tubercu- 
losis; founded  in  1903;  incorporated  in  1905.  President,  Edward 
O.  Otis,  M.D.;  Secretary,  Walter  E.  Kreusi,  4  Joy  Street. 

(For  a  report  of  the  work  of  this  Association  see  first  portion 
of  this  chapter.) 

BROCKTON. 

The  Brockton  Anti-Tuberculosis  Society.  President,  Mrs.  B.  B. 
Russell;  Secretary  and  Treasurer,  Mr.  Herbert  Tinkham;  Medical 
Director,  F.  J.  Ripley,  M.D. 

The  active  work  of  the  society  has  been  in  maintaining  an  ex- 
amining clinic  and  in  the  relief  work  which  has  developed  there- 
from. In  the  course  of  the  year  thirty-four  persons  have  been 
looked  after  either  in  their  homes,  where  the  cases  were  advanced, 
or  aided  to  go  to  Rutland  when  this  has  been  possible.  A  class 
is  conducted  for  early  cases  in  connection  with  the  clinic.  The 
relief  and  nursing  work  has  been  carried  on  by  the  society  nurse, 
for  a  portion  of  the  time  by  a  visiting  nurse.  Educational  work 
has  been  carried  on  by  the  distribution  of  leaflets  to  every  home 
in  the  city.     Striking  results  are  already  evident. 

The  funds  for  the  support  of  the  society  have  been  supplied  by 
the  Hon.  W.  E.  Douglas. 

Extension  of  the  educational  and  relief  work  will  be  carried 
on,  and  the  problem  of  suitable  employment  for  the  arrested  cases 
returning  from  Rutland  will  occupy  the  attention  of  the  society. 

BROOKLINE. 

The  Brookline  Anti-Tuberculosis  Society;  organized  in  May, 
1907.  President,  Mr.  Moses  Williams;  Secretary,  Miss  Hilda  W. 
Williams,  35  Walnut  Place. 

Brookline  is  one  of  the  few  communities  where  the  health  au- 
thorities have  been  active  leaders  in  the  tuberculosis  work.     The 


148  TUBERCULOSIS    IN    MASSACHUSETTS. 

principal  work  of  the  society  during  its  first  year  has  been  educa- 
tional in  character.  An  exhibit  was  held  and  a  series  of  illustrated 
lectures  given.  As  a  result,  the  society  has  more  than  three  hun- 
dred members,  and  an  auxiliary  department  started  among  the 
school  children  numbers  more  than  nine  hundred. 

Where  the  town  funds  cannot  be  called  upon  to  do  so,  the  board 
of  needy  consumptives  at  the  sanatorium  has  been  furnished. 
A  "sanitary  visitor"  is  employed  to  go  about  among  the  homes, 
giving  necessary  instruction  in  hygiene.  Recently  (1908)  a  day- 
camp  sanatorium  has  been  opened,  and  with  it  a  school  of  out- 
door life  for  children  having  incipient  tuberculosis. 

The  school  inspection,  registration  of  tuberculosis  cases  and 
disinfection  are  well  looked  after. 

CAMBRIDGE. 

The  Cambridge  Anti-Tuberculosis  Association;  organized  in 
October,  1903.  President,  Eugene  A.  Darling,  M.D.;  Secretary, 
Miss  Mabel  L.  Greeley,  689  Massachusetts  Avenue. 

This  is  one  of  the  earliest  associations  organized  to  deal  with 
the  tuberculosis  problems,  and  its  work,  centring  in  a  community 
of  about  one  hundred  thousand  inhabitants,  has  been  of  the 
greatest  value.  It  is  supported  by  voluntary  contributions  of 
the  members,  and  during  the  last  year  the  running  expenses  of 
the  association  were  $2,125,  ^^^  ^^^  relief  work  among  the  tuber- 
culosis cases  amounted  to  $1,230.  |f 

The  educational  work  has  been  pushed  till  there  is  active  sup- 
port among  the  citizens  at  large  and  efficient  co-operation  on  the 
part  of  the  municipal  authorities.  The  Association  has  main- 
tained a  separate  index  catalogue  of  the  cases  of  tuberculosis,  and 
the  Board  of  Health  has  a  catalogue  and  an  index  map. 

The  Association  maintains  a  free  tuberculosis  clinic,  which  is 
open  two  mornings  and  one  evening  each  week.     Half  the  time 


« 


STONE  —  KREUSI.  I49 

of  a  visiting  nurse  is  at  the  disposal  of  the  Association  in  its  relief 
work.  A  tuberculosis  class  is  maintained,  under  the  strictest 
rules. 

Recently  the  Board  of  Health  has  secured  ground  for  a  hos- 
pital for  the  care  of  tuberculosis,  and  has  opened  a  day-camp. 
Advanced  cases  have  also  been  cared  for  in  the  Holy  Ghost  Hos- 
pital. 

CHELSEA. 

The  Chelsea  Anti-Tuberculosis  Association;  organized  in  June, 
1907.     President,  Mr.  Thomas  B.  Frost,  8  Tudor  Street,  Chelsea. 

The  work  in  the  educational  line  has  been  confined  to  an  exhi- 
bition and  some  public  lectures.  The  principal  work  has  been  in 
dealing  with  individual  patients.  A  clinic  has  been  started  at 
the  Frost  Hospital.  After  the  disastrous  fire  of  April,  1908,  the 
clinic  was  continued  on  the  Carter  Street  grounds.  No  regular 
nurse  is  employed  in  the  relief|work,  but  volunteer  visitors  look 
up  the  cases  and  see  that  they  have  the  necessary  assistance. 

CLINTON. 

The  Clinton  Anti-Tuberculosis  Association.  President,  Dr.  W. 
P.  Bowers;  Secretary,  Miss  Ellen  K.  Stevens. 

The  Association  was  formed  in  June,  1908,  after  an  exhibition 
had  been  held  under  a  special  committee  largely  composed  of  the 
physicians  of  Clinton.  It  is  supported  by  membership  fees  and 
contributions.  It  expects  to  co-operate  with  the  Board  of  Health 
in  seeing  that  the  State  laws  are  enforced.  Plans  are  being  made 
to  establish  a  day  sanatorium  and  to  undertake  an  educational 
campaign. 

EVERETT. 

The  Everett  Association  for  the  Relief  and  Control  of  Tubercu- 
losis; organized  in  the  spring  of  1908.  President,  A.  A.  Jackson, 
M.D.,  357  Broadway. 


150  TUBERCULOSIS    IN    MASSACHUSETTS.  f 

The  organization  of  this  society  was  a  result  of  the  interest 
aroused  by  a  series  of  lectures  given  under  the  auspices  of  the 
Board  of  Health.  A  register  of  all  cases  reported  to  the  Board  of 
Health  is  being  kept.  The  Association's  present  main  object  is  to 
maintain  a  clinic  and  a  nurse,  so  as  to  render  efficient  aid  to  the 
consumptives  residing  in  Everett. 


I 


FALL    RIVER. 

Fall  River,  although  the  third  largest  city  in  the  Commonwealth, 
has  no  private  organization  for  the  protection  of  the  public  against 
tuberculosis.  In  the  city  hospital  a  small  provision  for  tubercu- 
lous cases  is  made  and  the  city  has  been  authorized  by  the  legis- 
lature to  build  a  large  hospital  especially  for  such  cases.  Indi- 
viduals have  succeeded  in  getting  outdoor  sleeping  provisions  for 
a  few  cases.  Indigent  persons  may  obtain  attendance  of  the  city 
physician  in  their  homes.  The  District  Nursing  Association  also 
does  all  in  its  power  to  assist  patients  in  their  homes. 

FITCHBURG. 

The  Fitchburg  Society  for  the  Control  and  Cure  of  Tuberculo- 
sis. President,  Mr.  Alvah  Crocker;  Secretary,  Miss  Susan  M. 
Turner,  145  Main  Street.  '  M 

An  exhibition  was  held  in  December,  1907.  The  relief  work  is 
carried  on  by  a  visiting  nurse.  A  registration  map  is  planned  for, 
in  order  that  the  location  of  the  patients  shall  be  fully  known. 
The  principal  branches  of  work  are  along  instructive  and  prevent- 
ive lines.  Every  member  of  the  family  is  examined  where  there 
is  or  has  been  a  case  of  tuberculosis.  The  Board  of  Health  has 
been  urged  to  do  more  thorough  fumigating  and  to  more  carefully 
inspect  the  sanitary  condition  of  houses,  and  also  to  furnish  tem- 
porary aid  for  indigent  cases.  The  program  for  further  activity 
is  to  have  a  day-camp  and  free  clinic  for  adults  and  children.     The 


It 


STONE  —  KREUSI.  I5I 

society  aids  indigent  persons  to  pay  their  board  in  a  sanatorium 
where  that  treatment  is  desired,  and  furnishes  milk,  eggs,  awnings, 
chairs,  etc.,  to  needy  patients  not  accepted  at  Rutland  who  are 
obliged  to  take  out-door  treatment  at  home.  The  society  co- 
operates with  the  Associated  Charities  and  the  Board  of  Health, 
gives  medicine,  obtains  proper  clothing,  furnishes  oil,  sputum 
flasks  (through  the  Board  of  Health),  paper  napkins  and  bags. 
One  patient  has  been  boarded  in  the  country. 

HAVERHILL. 

The  Haverhill  Association  for  the  Relief  and  Control  of  Tuber- 
culosis; organized  in  April,  1907.  President,  I.  J.  Clarke,  M.D.; 
Secretary,  Frank  H.  Coffm,  M.D.,  112  Emerson  Street. 

Haverhill  has  a  flourishing  society  of  about  seven  hundred  and 
fifty  members.  The  educational  work  has  been  carried  out  by  the 
distribution  of  anti-tuberculosis  literature  to  all  the  homes  of  the 
city,  and  is  being  still  further  extended  to  the  factories.  An 
exhibit  with  public  lectures  was  arranged  during  the  past  year.  A 
dispensary  has  been  established,  and  tuberculous  patients  are 
cared  for  under  the  class  system.  The  relief  work  is  carried  on  by 
a  visiting  nurse,  a  part  of  whose  time  is  at  the  disposal  of  the 
Association.  The  principal  work  at  present  is  in  building  balconies 
for  patients  to  sleep  in  at  night,  especially  those  who  continue  at 
their  work. 

HOLYOKE. 

The  Holyoke  Association  for  the  Prevention  and  Relief  of  Tu- 
berculosis; organized  in  February,  1907.  President,  C.  A.  Allen, 
M.D.;  Secretary,  Mrs.  R.  S.  Vining,  1235  Dwight  Street. 

The  Holyoke  Medical  Association  held  a  public  meeting  early  in 
February,  1907,  and  in  consequence  of  the  interest  then  aroused 
the  Association  was  soon  afterwards  organized. 

Five  thousand  leaflets,  printed  in  three  languages,  on  the  cause, 


152  TUBERCULOSIS    IN    MASSACHUSETTS. 

prevention  and  cure  of  tuberculosis,  were  distributed  throughout 
the  city  and  two  thousand  cards  were  given  to  the  school  children. 
A  series  of  lectures  were  delivered  by  the  president  in  the  churches. 
Later  an  exhibit  was  held,  lectures  being  given  during  the  evening. 
Starting  with  a  class  of  three  patients,  the  membership  soon  grew 
to  eighteen.  Some  were  aided  to  go  to  Rutland,  and  relief  was 
given  to  advanced  cases.  Much  personal  instruction  was  given 
at  the  homes  of  the  patients  by  the  visiting  nurse.  A  day-camp 
has  been  recently  started,  and  is  in  a  flourishing  condition. 

LAWRENCE. 

The  Lawrence  Anti-tuberculosis  League;  organized  in  Novem- 
ber, 1907.  President,  C.  G.  Carleton,  M.D.;  Secretary,  Mrs. 
Helen  L.  Sherman. 

Educational  work,  aided  by  an  exhibition,  has  been  carried  on. 
At  the  Lawrence  General  Hospital  a  clinic  for  the  examination- 
and  treatment  of  tuberculous  patients  has  been  established,  as 
well  as  a  day-camp  on  the  hospital  grounds.  A  number  of  needy 
advanced  cases  have  been  found  and  cared  for,  and  food  and  other 
necessities  supplied  in  some  instances. 

LOWELL. 

The  Lowell  Anti-tuberculosis  Association.  President,  Mrs. 
Frederick  T.  Greenhalge. 

The  active  work  of  the  Association  has  been  to  hold  an  exhibit 
and  conduct  a  campaign  of  education.  A  visiting  nurse  is  avail- 
able to  visit  the  sick  persons  coming  under  the  notice  of  the  Asso- 
ciation. Through  the  generosity  of  Frederick  F.  Ayer,  the  Lowell 
General  Hospital  now  has  a  thoroughly  equipped  tuberculosis 
department.  The  physicians  of  Lowell  are  especially  active  in 
the  tuberculosis  work,  and  have  an  energetic  committee.  A  day- 
camp  at  the  Lowell  General  Hospital  furnishes  accommodations 
for  twenty-eight  patients. 


♦ 


I 


STONE  —  KREUSI.  I  53 

LYNN. 

The  Lynn  Association  for  the  ReHef  and  Control  of  Tubercu- 
losis; organized  in  March,  1907.  President,  Rev.  Ernest  J.  Den- 
nen;  Secretary,  H.  W.  Newhall,  M.D. 

The  educational  campaign  was  first  inaugurated.  An  exhibition 
was  held  and  lectures  given.  Relief  work  was  at  once  started, 
and  half  the  time  of  a  visiting  nurse  secured.  A  successful  class 
of  tuberculous  patients  has  been  in  operation  from  the  beginning, 
an  examining  clinic  is  maintained,  and  recently  a  small  day-camp 
was  started.     The  total  expense  for  the  first  year  was  about  $400. 

MALDEN. 

The  Tuberculosis  Committee  of  the  Associated  Charities.  Chair- 
man, Godfrey  Ryder,  M.D.;  Secretary,  Mrs.  Edith  Macdonald. 

The  educational  campaign  has  consisted  in  public  meetings,  an 
exhibition  held  in  1906  and  articles  in  the  local  newspapers. 
Much  energy  was  spent  in  awakening  the  Board  of  Health  to  the 
importance  of  the  tuberculosis  problem.  A  great  amount  of  re- 
lief work  has  been  done  for  tuberculous  patients  and  their  families. 
A  separate  index  map  has  been  maintained,  so  that  the  location  of 
the  known  patients  can  be  studied.  The  committee  maintains  an 
examining  clinic,  held  Tuesday  morning  and  Saturday  evening. 

NEW    BEDFORD. 

The  Portuguese  League  for  the  Assistance  to  Consumptives; 
organized  in  October,  1906.     President,  John  C.  S.  Pitta,  M.D. 

In  addition  to  relief  work  and  nursing  in  the  home,  in  which  the 
League  has  been  aided  by  the  Instructive  District  Nursing  Asso- 
ciation, a  day-camp  has  been  started,  where  beds  have  been  pro- 
vided for  patients  needing  absolute  rest,  but  who  were  not  sick 
enough  to  demand  much  actual  nursing.  The  League  has  had 
the  faith  to  incur  a  debt  of  over  1 1,500  in  connection  with  this 


154  TUBERCULOSIS    IN    MASSACHUSETTS. 

camp.  In  the  near  future  it  is  hoped  to  extend  the  usefulness  of 
the  camp  by  increasing  the  building  and  having  a  physician  in 
constant  attendance.  The  expenses  of  the  League  in  the  last 
year  were  $2,143, 

The  New  Bedford  Anti-Tuberculosis  Association.  President, 
J.  A.  McAllister. 

Relief  and  educational  work  among  the  citizens  and  mill  opera- 
tives has  been  carried  on. 

NORTHAMPTON. 

The  Northampton  Association  for  the  Prevention  and  Control 
of  Tuberculosis.  President,  Albert  M.  Belden,  M.D.;  Secretary, 
Mrs.  Abbie  Huxley. 

An  exhibition  has  been  held  and  general  educational  work  done, 
to  arouse  an  active  public  sentiment.  Special  efforts  are  being 
made  to  get  persons  interested  in  order  to  obtain  money  with 
which  to  build  a  ward  at  the  local  hospital,  to  be  devoted  to  the 
care  of  tuberculous  patients.  A  free  evening  examining  clinic  is 
held,  and  plans  are  being  developed  for  the  systematic  care  of  the 
patients  that  are  found  to  be  tuberculous.  The  relief  and  home 
instruction  is  carried  on  by  the  district  visiting  nurse.  Board  in 
sanatoria,  and  proper  food,  have  been  furnished  in  individual 
cases. 

PITTSFIELD. 

The  Pittsfield  Anti-Tuberculosis  Society.     President,  J.  F.  A. 
Adams,  M.D.;  Secretary,  Miss  Julia  W.  Redfield. 
The  association  has  been  but  recently  organized. 

SALEM. 

The  Tuberculosis  Committee  of  the  Associated  Charities;    or- 
ganized in  May,  1907.     Chairman,  Mr.  G.  Arthur  Bodwell. 
The  work  of  education  has  been  carried  on  by  means  of  a  public 


STONE  —  KREUSI.  I  55 

exhibit  and  lectures,  supplemented  by  the  distribution  of  tuber- 
culosis literature.  Relief  work  has  been  conducted  by  employing 
half  of  the  time  of  a  visiting  nurse,  who  has  given  instruction  in 
the  homes  of  the  patients.  Further  relief  work  in  furnishing 
supplies  has  been  done  in  destitute  cases.  An  examining  clinic 
and  a  special  class  for  tuberculosis  patients  is  conducted  at  the 
Salem  Hospital.  A  day-camp  has  also  been  recently  started. 
The  office  of  the  committee  is  open  three  days  each  week  through- 
out the  day.    The  expenses  have  been  about  I30  each  month. 

SPRINGFIELD. 

The  Springfield  Association  for  the  Prevention  of  Tuberculosis; 
organized  in  1907.  President,  H.  C.  Emerson,  M.D.;  Secretary, 
Mr.  Clinton  E.  Bell. 

Although  the  work  was  started  in  this  city  several  years  ago, 
no  association  was  organized  until  last  year.  The  Association 
has  an  examining  clinic,  and  the  systematic  care  of  the  tuberculous 
patients  in  their  homes  has  recently  been  organized.  As  yet  there 
is  no  visiting  nurse. 

WALPOLE. 

The  Walpole  Association  for  the  Relief  and  Control  of  Tubercu- 
losis; organized  in  1907.  President,  Secretary  and  Treasurer, 
Eleanor  Way-Allen,  M.D. 

Walpole  is  a  small  town,  and  the  work  has  been  largely  educa- 
tional, and  has  consisted  of  an  exhibit,  lectures  and  the  distribution 
of  literature  to  the  voters  of  the  town  and  to  the  factory  employees. 
The  factories  have  been  placarded  with  anti-expectoration  notices, 
and  provided  with  cuspidors.  Employees  who  are  in  suspiciously 
poor  health  are  examined,  and  when  found  to  be  tuberculous,  if 
necessary  assisted  to  go  to  Rutland.  In  the  relief  work  a  number 
of  individual  cases  have  been  helped.  Funds  for  the  work  have 
come  largely  from  a  single  individual. 


156  TUBERCULOSIS    IN    MASSACHUSETTS. 

WALTHAM. 

The  Waltham  Anti-Tuberculosis  Society;  organized  in  June, 
1908.  President,  Mr.  George  A.  Fiel;  Secretary,  Charles  B. 
Fuller,  M.D. 

The  society  will  continue  the  work  already  done  by  the  District 
Nursing  Association.  The  Waltham  Hospital  has  agreed  to  take 
certain  cases  of  tuberculosis,  on  request  of  the  Board  of  Health. 

WINCHESTER. 

The  Winchester  Visiting  Nursing  Association.  President,  Mrs. 
Joshua  Coit;  Secretary,  Mrs.  E.  C.  Oilman. 

The  Association  has  taken  up  special  tuberculosis  work,  and  is 
entitled  to  a  place  in  this  list.  It  maintains  a  special  clinic  at  the 
Association  rooms,  and  provides  for  the  systematic  treatment  of 
the  tuberculosis  patients.  Relief  work  is  done  by  two  nurses  em- 
ployed by  the  Association.  Board  and  other  forms  of  aid  have 
been  freely  given.  In  co-operation  with  the  Women's  Club,  litera- 
ture upon  tuberculosis  and  general  hygiene  has  been  distributed. 
Public  sentiment  has  also  been  aroused  to  favor  the  enforcement 
of  the  town  ordinances  against  expectoration  on  sidewalks  and  in 
public  buildings. 

WOBURN. 

The  Woburn  Medical  Association;    organized  in   1908.     Presi- 
dent, Robert  Chalmers,  M.D.;  Secretary,  M.  M.  Stevens,  M.D. 
A  day-camp  was  opened  June  15,  1908. 

WORCESTER. 

The  Worcester  Tuberculosis  Relief  Association;  organized  in 
January,  1904;  incorporated  in  1907.  President,  Albert  C. 
Getchell,  M.D.;  Treasurer  and  Clerk,  Mr.  Earle  Brown. 

The  Tuberculosis  Relief  Association  has  co-ordinated  all  the 
various  charities  and  activities  in  the  city,  so  far  as  possible.     It 


STONE  —  KREUSI.  I  57 

has  distributed  leaflets,  provided  lectures,  maintained  the  tuber- 
culosis exhibit,  conducted  a  propaganda  through  the  press,  fur- 
nished free  sputum  boxes  and  given  relief. 

This  year  a  nurse  has  been  employed,  whose  whole  time  is  given 
to  this  work.  She  is  in  regular  attendance  at  both  the  tubercu- 
losis clinics,  visits  all  patients  who  apply  there  and  such  other 
patients  as  are  referred  to  her  either  by  private  physicians  or  by 
others.  She  notifies  the  Board  of  Health  in  case  of  removal  or 
death,  and  sees  to  it  that  premises  are  properly  disinfected.  The 
District  Nursing  Society  is  depended  on  for  the  continued  nursing 
of  some  cases. 

The  Memorial  Hospital  and  the  Worcester  City  Hospital  each 
maintains  a  tuberculosis  clinic.  One  of  the  assistant  physicians 
at  the  City  Hospital  clinic  directs  the  outside  work  of  that  insti- 
tution, making  as  many  visits  as  are  necessary  in  co-operation 
with  the  tuberculosis  nurse.  The  Association  has  not  organized 
classes,  because  it  thinks  individual  work  is  more  effective,  and 
so  far  its  machinery  is  adequate  for  that  work.  It  endeavors  to 
send  all  suitable  patients  to  the  State  Sanatorium,  furnishing,  if 
need  be,  the  funds  direct,  or  providing  them  from  other  charities. 


I  c,S  TUBERCULOSIS    IN    MASSACHUSETTS. 


CHAPTER    XII. 

EXPERIMENTAL     RESEARCHES      IN     TUBERCULOSIS,     WITH 

SPECIAL  REFERENCE    TO    ETIOLOGY,   PATHOLOGY  AND 

IMMUNITY. 

Theobald  Smith,  M.D. 

Activities  which  belong  to  the  field  of  medical  science  may  be 
grouped  into  researches  concerned  with  the  nature  and  causation 
of  pathologic  phenomena,  and  those  concerned  with  the  applica- 
tion of  the  knowledge  disclosed  to  the  prevention  and  treatment 
of  disease. 

To  trace  these  activities  over  a  definite  geographic  area,  such 
as  a  State,  is  difficult,  for  research  in  any  subject  which  concerns 
the  population  of  the  world  goes  on  simultaneously  in  many  places. 
The  stream  of  research  activities  is  continuous  only  when  we  bring 
into  our  view  the  entire  civilized  world.  When  we  view  a  small 
territory,  it  is  more  like  examining  separate  brooks  having  no  con- 
nection with  one  another,  which,  however,  eventually  contribute 
to  the  main  stream.  These  researches  emanate  largely  from  labo- 
ratories, and  are  experimental  in  character.  They  differ  from 
those  of  practical  medicine  only  in  so  far  as  the  conditions  under 
which  the  special  problems  of  disease  are  being  investigated  are 
either  known,  or  else  controlled  or  carefully  balanced  by  unknown 
factors  of  presumably  equal  value.  This  use  of  controls  is  the 
more  extended,  the  larger  the  number  of  unknown  elements  which 
enter  into  the  problem,  it  is  either  impossible  or  possible  only 
through  the  use  of  statistics  or  the  accumulation  of  numbers  of 
cases  that  the  practice  of  medicine  can  control  its  work.  Beyond 
this  there  is  no  fundamental  distinction,  nor  even  any  sharp  divid- 
ing line  between  experimental  and  clinical  medicine.  One  in- 
sensibly shades  into  the  other  by  gradations.     The  hope  of  con- 


SMITH.  159 

tinued  and  greater  success  in  the  limitation  of  disease  lies  in  slowly 
pushing  the  methods  of  experimental  medicine  into  clinical  work. 
This  has  been  going  on  to  a  very  large  extent  by  the  development 
of  hospital  laboratories.  Laboratory  activities  on  a  large  scale 
are  co-extensive  with  the  modern  era  of  bacteriology,  and  this  in 
turn  has  as  its  chief  starting  point  the  discovery  of  the  tubercle 
bacillus  by  Koch  in  1882. 

These  activities  are  grouped  in  the  main  around  three  epochs  in 
the  development  of  our  knowledge  of  tuberculosis,  —  the  discovery 
of  the  tubercle  bacillus,  the  introduction  of  tuberculin  as  a  cura- 
tive and  diagnostic  agent,  and  the  differentiation  of  the  races  of 
mammalian  tubercle  bacilli  provisionally  into  human  and  bovine. 
Each  event  acted  as  a  stimulus,  aroused  the  waning  interest  in  the 
nature  and  activities  of  the  tubercle  bacillus,  and  supported  the 
flagging  hope  for  the  discovery  of  some  easily  applied  curative  or 
immunizing  agent. 

The  period  preceding  the  discovery  of  the  tubercle  bacillus  was 
devoted  chiefly  to  the  macroscopic  and  microscopic  study  of  the 
tubercle,  and  to  speculations  concerning  its  origin  and  nature. 
Though  the  infectious  properties  of  tuberculous  matter  had  been 
demonstrated  by  Kleucke  in  1843  and  again  by  Villemin  in  1865, 
yet  the  conception  of  infection  from  without  with  reference  to  this 
disease  did  not  seem  to  flourish  or  to  lay  hold  of  medical  thinking.' 

Among  the  writings  emanating  from  Massachusetts  during  the 
period  preceding  the  discovery  of  the  tubercle  bacillus  perhaps  one 
may  be  mentioned,  as  it  is  based  upon  macroscopic  and  microscopic 
examination  of  tuberculous  and  other  tissue  from  sixteen  cases. 
I  refer  to  the  Boylston  Prize  Essay  of  Calvin  Ellis,  entitled  "Tu- 
bercle: Its  Pathology  and  especially  its  Relation  to  inflamma- 
tion.'"    Ellis  described  the  macroscopic  and  microscopic  char- 


'  R.  H.  Fitz.     The  Theorj' of  Tuberculosis.     Mass.  Medical  Society.     1871. 
2  Am.  Joum.  Med.  Sc,  i860,  N.  S.     XXXIX,  339. 


l60  TUBERCULOSIS    IN    MASSACHUSETTS. 

acters  of  "gray  and  yellow"  tubercle,  its  chemical  characters  and 
metamorphoses.  He  discussed  its  distribution  in  the  body  and 
the  diseases  which  are  incompatible  with  it.  With  the  aid  of 
quotations  from  the  writings  of  Virchow,  Reinhardt  and  Spiess, 
he  analyzes  the  tuberculous  process  and  comes  to  the  following 
conclusions:  — 

It  [tubercle]  is  not  a  specific  exudation. 

It  does  not  exist  as  such  in  the  blood. 

The  yellow  variety  is  always  the  result  of  metamorphosis  —  of  degeneration. 

It  is  altogether  probable  that  it  is  owing  to  a  "  degraded  condition  of  the  nutri- 
tive material,"  which  differs  from  that  furnished  under  ordinary  circumstances, 
"  not  in  kind,  but  in  degree  of  vitality  or  capacity  for  organization." 

The  selection  and  grouping  of  publications  emanating  from  Mas- 
sachusetts since  the  discovery  of  the  tubercle  bacillus  has  been  a 
task  of  considerable  difficulty.  Only  those  papers  have  been 
chosen  which  presented  evidence  of  laboratory  work  done,  as 
contrasted  with  clinical  work,  to  support  the  statement  made 
and  conclusions  reached.  This  rule  of  choice  reduced  the  available 
material  to  a  relatively  small  amount. 

As  regards  the  order  of  presentation,  it  was  found  impracticable 
to  deal  with  the  publications  chronologically  or  with  reference  to 
the  three  epochs  mentioned  above,  and  it  was  deemed  best  to 
bring  together  those  which  are  logically  related  to  one  another. 

The  review  of  each  paper  has  been  purposely  made  short,  and 
the  author's  conclusions  cited  wherever  possible.  Critical  com- 
ments have  been  withheld  excepting  where  the  results  were  open 
to  doubt  and  at  the  same  time  of  great  practical  significance.  The 
writer  has  a  vague  presentiment  that  papers  have  been  overlooked 
which  should  have  been  included  in  this  chapter's  summary,  but 
he  hopes  that  the  neglected  authors  will  be  lenient  with  him  for 
his  shortcomings. 


SMITH.  l6l 

ETIOLOGY    OF    TUBERCULOSIS. 
The  Morphology  and  Biology  of  the  Tubercle  Bacillus. 

The  early  work  on  the  relation  of  the  tubercle  bacillus  to  tuber- 
culosis, its  morphology  and  cultivation  and  the  methods  used  for 
staining  it,  was  designed  largely  to  repeat  and  confirm  the  original 
work  of  Koch,  and  to  acquaint  the  medical  profession  with  the 
laboratory  methods  used  by  him  and  the  inferences  and  conclusions 
drawn  by  him  from  his  experiments.  This  period  has  little  origi- 
nality to  show.  The  progress  made  by  Koch  over  his  contempo- 
raries in  almost  everything  undertaken  by  him,  his  original  and 
advanced  points  of  view  and  his  new  methods  of  research,  left  all 
far  behind.  Koch  had  so  thoroughly  covered  the  field  that  it  re- 
quired years  to  discover  any  untilled  corners.  Moreover,  labora- 
tories were  just  being  created.  Apparatus  had  to  be  improvised, 
contrived  or  newly  invented  to  meet  the  sudden  expansion  of 
bacteriological  methods. 

Harold  C.  Ernst '  describes  his  experience  with  the  different 
staining  methods  then  in  use  and  gives  formulae  for  each.  He 
gives  his  preference  to  the  Koch  method.  He  also  describes  the 
method  for  procuring  pure  cultures  of  the  bacillus  of  tuberculosis, 
following  Koch's  directions  as  closely  as  possible,  and  cites  a  list  of 
the  pathological  material  submitted  to  microscopic  examination. 
Guinea-pigs  were  also  inoculated.  The  entire  work  is  in  a  sense  a 
repetition  and  confirmation  of  a  portion  of  Koch's  original  inves- 
tigation. 

E.  W.  Gushing '  gives  an  exhaustive  summary  of  Koch's 
original  monograph  on  the  bacillus  of  tuberculosis.  In  a  second 
paper  ^  an  account  of  the  methods  of  staining  the  bacilli  and  the 
manipulation  of  the  microscope  for  their  detection  is  given. 

1  Amer.  Journ.  Med.  Sciences.     1884.     LXXXVIII,  367. 

2  Bost.  Med.  &  Surg.  Journ.     1885.    CXI  II,  533. 

3  Ibid.     1886.     CXIV,  277. 


1 62  TUBERCULOSIS    IN    MASSACHUSETTS. 

A  similar  paper  was  published  by  W.  F.  Whitney.' 

The  pathology  of  cutaneous  tuberculosis  was  discussed  by  John 
T.  Bowen  ^  with  special  reference  to  miliary  tuberculosis  of  the 
skin,  scrofuloderma,  lupus  and  tuberculosis  verrucosa  cutis.  The 
pathological  anatomy  of  these  lesions  is  carefully  described  with 
reference  to  the  primary  seat  of  the  lesion,  the  formation  of  the 
specific  tuberculous  tissue,  the  degenerations  and  regenerations 
associated  with  it. 

A  similar  paper  was  published  by  C.  J.  White'  in  1905.  Dr. 
White's  treatment  of  the  subject  approaches  the  clinical,  and  is 
descriptive  of  the  various  well  determined  and  debated  forms  of 
skin  tuberculosis.  Inasmuch  as  the  descriptions  are  limited  to 
the  naked-eye  appearances,  the  paper  belongs  more  properly 
among  the  clinical  contributions. 

The  resistance  of  tubercle  bacilli  to  destruction  by  drying  has 
been  of  great  interest  to  sanitarians,  in  view  of  the  current 
theory  that  pulmonary  tuberculosis  is  largely  an  inhalation 
disease. 

In  1890  Dr.  A.  K.  Stone*  tested  on  rabbits  three  lots  of  sputum 
in  which  tubercle  bacilli  had  been  demonstrated  about  three  years 
before.  The  sputum  remained  on  "the  laboratory  shelves  quiet 
and  undisturbed"  during  this  long  period.  When  it  was  used  upon 
rabbits,  the  sputum  was  represented  either  by  a  little  dry  dust  or 
else  by  a  hard  brown  crust  covering  the  bottom  of  the  jar.  The 
notes  on  the  inoculated  rabbits  suggest  local  tuberculosis  of  limited 
extent.  The  proof  that  tubercle  bacilli  may  survive  so  long  under 
the  conditions  mentioned  should  have  been  strengthened  by  either 
cultures  or  subinoculations  from  the  original  rabbits,  since  the  re- 
sults are  at  variance  with  those  of  other  investigators. 

'  "  The  Etiology  of  Tuberculosis."     Riverside  Press,  Cambridge,  1882. 

•  Bost.  Med.  &  Surg.  Joum.     1891.    CXXV,  516. 
3  Bost.  Med.  &  Surg.  Joum.     1905.     CLIII,  291. 

*  Amer.  Joum.  Med.  Sc.     i8gi.     CI,  275. 


I 


SMITH. 


163 


The  thermal  deathpoint  of  tubercle  bacilli  was  investigated  by 
the  writer '  primarily  to  determine  any  possible  differences  in  this 
respect  between  the  human  and  bovine  types.  No  differences 
were  discovered,  but  earlier  observations  were  rectified  by  demon- 
strating that  the  tubercle  bacillus  is  killed  in  fluids  by  twenty 
minutes'  exposure  at  60°  C,  and  that  former  discrepancies  are 
accounted  for  by  the  fact  that  in  milk  a  pellicle  forms  which  pro- 
tects the  bacilli  from  the  heat.  By  heating  milk  in  closed  vessels 
this  difficulty  is  eliminated. 

TUBERCULIN. 
Infection  and  Immunity. 

The  second  era  or  epoch  in  the  investigation  of  tuberculosis  was 
ushered  in  with  the  announcement  in  1890  that  a  cure  for  tuber- 
culosis had  been  discovered  by  Koch.  Again  a  number  of  publica- 
tions appeared,  but  they  were  chiefly  the  results  of  observations 
made  on  patients  to  test  the  statement  of  Koch  that  tuberculin 
was  curative.  Slowly  the  tide  turned  against  this  new  substance, 
for  good  and  obvious  reasons,  for  Koch  had  simply  discovered 
what  would  now  be  called  an  instance  of  anaphylaxis  or  the  sensi- 
tization of  the  human  being,  by  virtue  of  infection,  to  certain  ex- 
tracts of  the  tubercle  bacillus.  The  immense  impetus  given  to 
research  by  this  and  the  nearly  contemporaneous  discovery  of 
antitoxin  by  von  Behring  brought  into  the  foreground  for  investi- 
gation the  problem  of  immunity,  of  which  the  tuberculin  reaction 
was  but  a  fragment.  This  great  problem,  long  nurtured  by  the 
genius  of  Pasteur,  slumbered  elsewhere  until  awakened  by  these 
great  discoveries.  Even  after  seventeen  years,  immunity  still 
presents  subsidiary  problems  of  the  greatest  importance  to  the 
science  of  biology  and  to  the  practice  of  medicine. 

Belonging  to  this  period  there  is  one  paper  which  should  be 

1  Journ.  Exper.  Med.     iSgg.     IV,  217. 


164  TUBERCULOSIS    IN    MASSACHUSETTS. 

mentioned  here.  J.  A.  Jeffries'  made  extracts  of  tubercle  bacilli 
with  alcohol,  ether,  chloroform  and  benzol,  as  well  as  glycerine. 
Tuberculous  guinea-pigs  were  made  very  sick  with  the  latter.  The 
series  of  experiments  was  interrupted  by  an  accident.  This  paper 
was  in  line  with  Koch's  work,  but  unfortunately  was  not  completed. 

Among  the  papers  belonging  to  this  chapter,  but  published  at  a 
much  later  date,  the  following  embody  considerable  laboratory 
work.  A  painstaking  investigation  on  the  effect  of  tuberculins 
made  from  human  and  bovine  tubercle  bacilli  was  published  by 
S.  B.  Wolbach  and  Harold  C.  Ernst'  in  190^;.  Cultures  were 
freshly  isolated  directly  from  the  respective  hosts,  and  tuberculin 
made  in  the  usual  way.  The  relative  virulence  of  the  human  and 
the  bovine  culture  was  first  determined  in  rabbits  and  guinea-pigs. 
The  tuberculins  were  next  tested  on  tuberculous  guinea-pigs,  and 
it  was  found  that  both  acted  alike  upon  guinea-pigs  infected  with 
human  or  bovine  bacilli.  Finally,  inoculated  guinea-pigs  were 
treated  with  small  doses  of  tuberculin.  Eighteen  were  inoculated 
with  human  and  an  equal  number  with  bovine  bacilli.  One-half 
of  each  set  was  treated  with  human,  the  other  half  with  bovine 
tuberculin.  The  results  were  more  or  less  conflicting,  but  it  was 
noticed  that  many  treated  guinea-pigs  gained  in  weight  and  in 
some  the  local  ulcer  healed.  The  contents  of  the  local  inoculation 
abscess  also  discharged  more  rapidly  and  completely  in  the  treated 
than  in  the  control  animals.  The  inference  was  that  the  tuber- 
culin treatment  on  the  whole  acts  favorably  upon  tuberculous 
guinea-pigs. 

In  a  paper  presented  before  the  Harvey  Society  of  New  York, 
the  writer'  goes  into  the  subject  of  infection  and  immunity  in 
tuberculosis.  He  discusses  the  portals  of  entry,  and  points  out 
the  fact  observed  by  him  in  a  large  number  of  autopsies  in  1893, 
that  in  cattle  the  primary  foci  of  infection  are  the  regional  lymph 

'  Bost.  Med.  &  Surg.  Joum.     1891.     CXXVI,  185. 

'  Journ.  Med.  Research.     XII,  295. 

3  Journ.  Amer.  Med.  Assoc.     1906.     XLVI,  1247  and  1345. 


i 


SMITH.  165 

nodes  of  the  throat,  the  lungs  and  the  small  intestines,  and  only 
very  rarely  the  organs  or  mucous  membranes  through  which  the 
bacilli  must  pass  to  the  lymph  nodes.  The  action  of  dead  tubercle 
bacilli  and  of  tuberculin  is  discussed  on  the  basis  of  a  large  series 
of  experiments  on  guinea-pigs  by  him,  and  the  earlier  experiments 
of  Straus,  Prudden  and  others.  Lastly,  the  problem  of  vaccina- 
tion with  tubercle  bacilli  killed  at  60°  C.  is  taken  up  and  recom- 
mended as  a  means  of  suppressing  the  disease. 

In  recent  years  the  suppression  of  bovine  tuberculosis  by  means 
of  vaccination  has  been  strongly  advocated  by  von  Behring,  and  a 
method  developed  by  him  on  a  commercial  scale  which  has  been 
applied  in  many  countries.  The  desire  to  obtain  first-hand  in- 
formation concerning  the  efficacy  of  this  method  led  the  Massa- 
chusetts Society  for  Promoting  Agriculture  to  grant  the  writer 
a  certain  sum  of  money  to  carry  on  a  series  of  vaccination  tests 
on  calves.' 

The  outcome  of  these  investigations  demonstrated,  as  had  been 
done  by  Koch  and  co-workers  in  Germany,  that  almost  any  human 
type  of  tubercle  bacillus  could  be  used  in  place  of  the  bovovaccine, 
and  that  the  vaccine  could  be  easily  and  cheaply  prepared  by  those 
who  were  acquainted  with  the  chief  characters  of  the  human 
tubercle  bacillus.  It  was  also  clearly  shown  that  the  immunity 
due  to  two  injections  of  suspensions  of  human  bacilli  is  not  quite 
high  enough,  and  the  writer  suggests  for  valuable  animals  a  third 
injection  of  attenuated  bovine  bacilli. 

PUBLIC-HEALTH    ASPECTS    OF    TUBERCULOSIS. 
Transmission  from  Man  to  Man  and  from  Animals  to  Man. 

The  presence  of  tubercle  bacilli  in  the  milk  of  tuberculous  cows 
with  apparently  normal  udders  was  investigated  by  Harold  C. 
Ernst,'  assisted  by  Drs.  Austin   Peters,  Henry  Jackson  and   L. 

'  Joum.  Med.  Research.     1908,  XVIII,  451- 

2  Amer.  Joum.  Med.  Sciences.  iSSg,  XCVIII,  439-  Infectiousness  of  Milk.  1S94.  141.  17 
plates. 


l66  TUBERCULOSIS    IN    MASSACHUSETTS. 

Frothingham.  Tubercle  bacilli  were  seen  in  coverslip  prepara- 
tions of  the  milk  of  twelve  out  of  thirty-six  cows.  By  inoculation 
of  guinea-pigs,  tubercle  bacilli  were  detected  in  the  milk  of  six  out 
of  fifteen  cows.  By  the  inoculation  of  rabbits,  the  milk  of  four 
out  of  nineteen  cows  was  found  infected  with  tubercle  bacilli. 
Feeding  experiments  were  also  instituted  on  a  large  scale  with 
calves,  pigs  and  rabbits,  with  results  corroborating  those  obtained 
by  inoculation. 

At  the  same  time  samples  of  milk  and  cream  from  the  supply  of 
the  city  of  Boston  were  subjected  to  microscopic  examination  and 
inoculation.  The  results  were  as  follows:  in  thirty-three  samples, 
tubercle  bacilli  were  detected  with  the  microscope  once,  and  three 
times  in  inoculated  rabbits.  The  rest  of  the  volume  contains 
letters  from  practitioners  bearing  upon  clinical  observations  of 
tuberculosis  traceable  to  the  milk  supply.  As  this  portion  is  of 
clinical  rather  than  scientific  value,  it  does  not  come  within  the 
scope  of  this  chapter.  The  conclusions  reached  by  the  author  are 
as  follows :  — 

1.  While  the  transmission  of  tuberculosis  by  milk  is  probably  not  the  most 
important  means  by  which  the  disease  is  propagated,  it  is  something  to  be  guarded 
against  most  carefully. 

2.  The  possibility  of  milk  from  tuberculous  udders  containing  the  infectious 
element  is  undeniable. 

3.  With  the  evidence  here  presented,  it  is  equally  undeniable  that  milk  from 
diseased  cows  with  no  appreciable  lesion  of  the  udder  may,  and  not  infrequently 
does,  contain  the  bacillus  of  the  disease. 

4.  Therefore,  all  such  milk  should  be  condemned  as  food. 

Dr.  F.  T.  Lord  contributes  an  important  article  on  flies  and 
tuberculosis.'  As  the  result  of  laboratory  experiments  with  flies, 
in  which  feeding  of  sputum  was  practised  and  the  fly-specks 
studied,  the  following  conclusions  were  reached:  — 

I.  Flies  may  ingest  tubercular  sputum  and  excrete  tubercle  bacilli,  the  viru- 
lence of  which  may  last  at  least  fifteen  days. 

'  Bost.  Med.  &  Surg.  Journ.     1904,  CLI,  651. 


SMITH.  167 

2.  The  danger  of  human  infection  from  tubercular  fly-specks  is  by  the  ingestion 
of  the  specks  on  food.  Spontaneous  liberation  of  tubercle  bacilli  from  fly-specks 
is  unlikely.  If  mechanically  disturbed,  infection  of  the  surrounding  air  may 
occur. 

As  a  corollary  to  these  conclusions,  it  is  suggested  that:  — 

3.  Tubercular  material  (sputum,  pus  from  discharging  sinuses,  fecal  matter 
from  patients  with  intestinal  tuberculosis,  etc.)  should  be  carefully  protected  from 
flies,  lest  they  act  as  disseminators  of  the  tubercle  bacilli. 

4.  During  the  fly  season,  greater  attention  should  be  paid  to  the  screening  of 
rooms  and  hospital  wards  containing  patients  with  tuberculosis,  and  laboratories 
where  tubercular  material  is  examined. 

5.  As  these  precautions  would  not  eliminate  fly  infection  by  patients  at  large, 
food  stuffs  should  be  protected  from  flies  who  may  already  have  ingested  tuber- 
cular material. 

THE     INTERRELATION      OF      HUMAN      AND      ANIMAL      TUBER- 
CULOSIS. 

Variation  among  Tubercle  Bacilli. 

The  identity  of  tubercle  bacilli  isolated  from  cattle  and  man  had 
been  regarded  as  definitely  established  by  the  great  work  of  Koch 
published  in  1884.  Ten  years  later,  sanitary  measures  based  upon 
this  assumed  identity  and  the  discovery  of  tuberculin  as  a  diag- 
nostic agent  were  in  force  in  all  civilized  countries.  In  some  the 
zeal  to  wipe  out  bovine  tuberculosis  obscured  for  a  time  the  more 
important  issue  of  the  transmission  of  tuberculosis  from  man  to 
man,  when  it  became  known  through  the  use  of  tuberculin  to  what 
extent  cattle  were  infected  with  tuberculosis.  The  discovery  of 
Maflfucci,  that  the  tubercle  bacillus  of  birds  was  a  distinct  race  or 
variety,  had  been  accepted  by  Koch  himself. 

That  bovine  and  human  bacilli  are  not  identical  had  occurred  to 
the  writer  in  studying  the  inoculation  disease  in  guinea-pigs.  In 
1894-95  two  cultures,  one  from  cattle,  and  one  presumably,  though 
indirectly,  of  human  origin,  were  studied  in  Washington,  D.  C, 
and  tested  in  cattle,  and  such  great  differences  discovered  that 
further  studies  were  at  once  begun.    This  first  communication 


l68  TUBERCULOSIS    IN    MASSACHUSETTS. 

was  not  published  until  1896,  but  the  subject  began  to  arouse  some 
interest  and  considerable  opposition.  L.  Frothingham '  inves- 
tigated the  subject  for  the  Massachusetts  Cattle  Q)mmission,  and 
published  his  results  in  1897. 

A  culture  of  human  bacilli  was  used,  isolated  from  the  liver  of 
a  child,  and  about  one  year  old.  Two  calves,  three  months  and 
three  weeks  old  respectively,  received  suspensions  of  the  culture 
into  the  peritoneal  cavity.  In  both  only  slight  local  nodules  were 
produced,  some  resembling  spontaneous  tubercle,  others  tending 
towards  granulation  tissue.  Two  calves,  three  weeks  and  two 
months  old  respectively,  were  inoculated  into  the  trachea.  In 
one  case  the  large  local  abscess  in  the  muscles  of  the  neck  indicated 
a  deposit  there  of  much  of  the  material  destined  for  the  lungs. 
In  the  Hver  and  lungs  a  small  number  of  minute  tubercles,  practi- 
cally devoid  of  tubercle  bacilli,  were  found.  In  the  other  calf 
lesions  were  absent.  Thus,  in  spite  of  the  immature  age  of  these 
animals,  the  tubercle  bacillus  may  be  said  to  have  had  but  a  trifling 
local  effect  on  them.  The  tests  on  guinea-pigs  indicate  a  very 
attenuated  culture. 

In  a  second  experiment  human  sputum  containing  many  bacilli 
was  inoculated  under  the  skin  of  one  calf  and  into  the  trachea  of 
two  others.  The  animals  were  killed  four  to  five  months  after 
inoculation.  The  subcutaneous  inoculation  was  apparently  neg- 
ative. In  the  others  the  lungs  were  normal,  the  muscular  tissue 
around  the  trachea  was  slightly  involved,  but  there  was  no  active, 
progressive  disease  from  this  focus. 

From  present  knowledge  of  the  effects  of  bovine  tubercle  bacilli 
on  young  calves,  we  may  say  that  neither  the  pure  culture  nor  the 
sputum  inoculated  by  Frothingham  contained  bovine  bacilli. 

In  1898  the  writer*  published  the  second  paper  on  the  com- 

'  Ann.   Rept.  Bd.  of  Cattle   Commissioners  of   the  Commonwealth  of   Mass.     Jan.  1897.     49. 
Translated  in  Ztschr.  f.  Thiennedizin,  1897.     I,  330. 
9  Jour.  Exper.  Med.     1898.     111,451. 


r 


SMITH.  169 

parative  study  of  human  and  animal  tubercle  bacilli.  This  inves- 
tigation included  seven  cultures  from  man,  five  from  cattle,  and  one 
each  from  a  pig,  a  cat  and  a  horse.  It  consisted  of  a  study  of  the 
morphological  and  cultural  characters  of  the  bacilli,  of  their  path- 
ogenic action  on  guinea-pigs,  rabbits,  mice,  pigeons  and  cattle, 
and  of  the  histological  character  of  the  lesions  produced.  Through- 
out an  effort  was  made  to  have  the  study  of  cultures  from  human 
and  bovine  sources  run  parallel.  Only  in  this  way  could  any  satis- 
factory basis  for  comparison  be  established. 

Inasmuch  as  in  this  paper  the  writer  has  formulated  nearly  all 
the  problems  which  have  since  then  occupied  the  attention  of  in- 
vestigators in  many  countries,  its  contents  are  best  reviewed  by 
a  few  direct  quotations:  — 

The  foregoing  experiments,  while  they  show  unmistakably  the  close  relation- 
ship existing  among  the  various  cultures  studied,  nevertheless  justify  us,  if  only 
to  guide  and  stimulate  further  study,  in  establishing  a  distinctively  human  or 
sputum  and  a  bovine  variety  of  the  tubercle  bacillus,  it  might  be  better  to  omit 
the  host  designation  of  such  varieties,  in  order  to  anticipate  assumptions  that  they 
are  necessarily  limited  to  the  host  whose  name  they  bear.  Still,  the  convenience 
of  using  the  host's  name  is  so  great  that  I  shall  succumb  to  it.  The  characters 
upon  which  the  bovine  variety  may  be  based  reside,  morphologically,  in  the  in- 
variably short,  straight  form  and  in  the  greater  resistance  of  this  form  to  modi- 
fying influences  of  culture-media;  biologically,  in  a  greater  resistance  to  artificial 
cultivation  and  in  a  much  greater  pathogenic  activity  towards  rabbits,  guinea- 
pigs  and  cattle. 

There  is  proof,  furthermore,  of  the  existence  of  slightly  varying  characters 
even  within  the  varieties  proposed.  Among  the  bovine  forms  studied,  slight  varia- 
tions in  virulence  were  noticeable.  Among  the  sputum  forms,  variations  in  size, 
in  capacity  for  cultivation,  and  in  pathogenic  activity  have  been  observed. 

Putting  all  the  facts  obtained  by  experiments  upon  cattle  together,  it  would 
seem  as  though  the  sputum  bacillus  cannot  gain  lodgment  in  cattle  through  the 
ordinary  channels.  These  avenues,  well  provided  with  protective  mechanisms, 
receive  the  bacilli  probably  one  at  a  time.  However  closely  the  sputum  and  the 
bovine  bacillus  may  be  related,  it  seems  as  if  under  ordinary  circumstances  the 
former  would  fall  an  easy  prey  to  destruction.  This  inference  will  gain  in 
weight  if  we  bear  in  mind  that  the  far  more  potent  bovine  bacillus  produces  in  at 
least  50  per  cent,  of  the  spontaneously  infected  cattle  a  purely  local  disease,  which 


lyo  TUBERCULOSIS    IN    MASSACHUSETTS. 

probably  would  remain  so  if  the  animal  were  surrounded  with  favorable  con- 
ditions. 

The  second  and  most  important  proposition,  the  transmission  of  bovine  bacilli 
to  the  human  subject,  has  been  much  discussed  in  recent  years,  without,  however, 
bringing  us  any  nearer  to  definite  knowledge. 

If  bovine  bacilli  may  invade  the  human  body  without  let  or  hindrance,  we  have 
not  only  food  infection  through  milk  and  milk  products  to  guard  against,  but  also 
the  inhalation  disease  to  which  men  are  exposed  in  stables  containing  tuberculous 
cattle.  What  proportion  of  tuberculous  subjects  may  derive  their  infection  from 
these  sources  we  do  not  know.  Now  that  we  have  established  some  fairly  pro- 
nounced differences  between  bovine  and  sputum  bacilli,  the  whole  discussion 
might  be  cut  short  by  the  suggestion  that  the  time  has  come  to  stop  citing  old  and 
doubtful  cases,  and  to  go  to  work  to  study  with  care  the  tubercle  bacilli  from 
cases  of  supposed  animal  origin,  so  that  some  experimental,  trustworthy  basis 
may  be  formed  upon  which  to  found  statistics. 

While  this  is  in  truth  what  will  have  to  be  done,  and  is  the  goal  which  has  been 
aimed  at  from  the  outset  in  this  tedious  work,  it  will  take  much  time  and  persistent 
attention  to  collect  evidence  of  this  kind.  In  the  mean  time,  the  relation  of  bovine 
to  human  tuberculosis  must  be  somehow  defined  before  a  fairly  helpless  and  fright- 
ened public.  It  seems  to  me  that,  accepting  the  clinical  evidence  on  hand,  bovine 
tuberculosis  may  be  transmitted  to  children  when  the  body  is  overpowered  by 
large  numbers  of  bacilli,  as  in  udder  tuberculosis,  or  when  certain  unknown  favor- 
able conditions  exist.  To  prevent  this  from  occurring,  a  rigid  periodic  dairy  in- 
spection and  the  removal  of  all  suspicious  udder  affections  and  all  emaciated 
animals  is  as  much  as  public  health  authorities  can  at  present  demand.  Any 
measures  beyond  these  belong  to  agriculture,  with  which  the  public  health  has  no 
business  to  meddle,  without  endangering  the  chances  of  gaining  authority  to  en- 
force its  own  necessary  measures.  If  the  evidence  gained  by  pathology  in  the 
future  should  reveal  a  greater  danger  than  is  here  assumed,  the  scientific  basis  of 
such  evidence  will,  I  think,  force  all  additional  measures  needed. 

But  for  the  student  of  etiology  the  problem  does  not  end  in  the  differentiation 
of  varieties.  It  reaches  out  much  farther  than  this,  and  involves  some  puzzling 
questions.  The  most  important  one  bears  on  the-  possible  changes  which  the 
tubercle  bacillus  may  undergo  during  its  prolonged  sojourn  in  the  human  body. 
I  have  already  referred  to  one  phase  of  this  question  in  mentioning  the  saprophytic 
growth  of  the  sputum  bacillus  in  the  affected  lungs  and  necrotic  tissue,  as  con- 
trasted with  its  slight  multiplication  in  living  tissue  and  with  the  generally  slight 
multiplication  of  the  bovine  bacillus  in  the  tissue  of  cattle.  This  question  is  a 
very  complicated  one,  and  nothing  is  easier  than  to  reason  in  a  circle  about  it, 
because  of  the  entire  absence  of  data.  The  first  hypothesis  to  be  considered  is 
that  which  assumes  the  conversion  of  the  bovine  bacillus  into  the  sputum  bacillus 
in  the  human  body.  .  .  . 


I 
I 


SMITH.  171 

The  question  of  phthisis  as  secondary  to  infection  by  way  of  the  digestive  organs 
is,  however,  one  needing  more  attention,  for  experimental  results  in  this  direc- 
tion are  quite  suggestive.  In  ail  mammals  the  lungs  are  evidently  the  most  fa- 
vored place  of  tubercle  bacilli,  and  wherever  the  latter  may  be  deposited,  they 
sooner  or  later,  unless  the  disease  is  checked,  reach  that  organ,  where  the  process 
spreads  more  rapidly  than  elsewhere.  This  march  from  the  place  of  infection 
is  not  infrequently  partially  concealed  by  reparative  processes.  .  .  . 

With  the  two  facts  before  us  that  tubercle  bacilli  gravitate,  as  it  were,  towards 
the  lungs  in  all  the  susceptible  mammals,  and  that  they  may  conceal  their  move- 
ments in  the  body  quite  effectually,  we  must  regard  infection  through  the  digestive 
tract  as  a  source  of  phthisis  at  least  deserving  more  attention.  The  only  question 
to  interest  us  here  is  the  relation  of  the  bovine  bacillus  to  this  process.  .  .  . 

Only  much  painstaking  work  will  enable  us  to  learn  whether  the  human  body 
can  produce  such  a  great  modification  of  the  bovine  bacillus  or  not. 

If  in  this  brief  summary  I  have  presented  nothing  but  problems  to  be  solved 
and  doubts  to  be  entertained,  I  feel  quite  confident  that  the  comparative  study 
of  tubercle  bacilli  will  lead  to  some  definite  understanding  on  certain  important 
questions,  and  eventually  to  more  light  on  the  whole  subject  of  tuberculosis,  from 
the  preventive  as  well  as  the  therapeutic  side. 

The  main  questions  proposing  themselves  to  the  investigator  are:  — 

1.  The  study  of  tubercle  bacilli  from  different  types  of  tuberculosis,  to  deter- 
mine their  relation  to  the  sputum  bacillus  and  the  bovine  bacillus  as  regards  viru- 
lence. 

2.  The  study  of  the  bacilli  in  primary  intestinal  disease  and  in  all  tubercular 
disease  in  children  in  which  the  source  of  infection  is  assumed  to  be  outside  of 
the  family  and  possibly  in  the  milk. 

The  work  of  studying  tubercle  bacilli  from  different  sources  was 
continued  as  opportunity  presented  itself  until  1907.  It  was  then 
taken  up  in  the  writer's  laboratory  by  Dr.  P.  A.  Lewis,  who  has 
succeeded  in  isolating  and  studying  from  all  points  of  view  cul- 
tures from  fifteen  cases  of  tuberculous  cervical  and  mesenteric 
lymph  nodes  in  children.  As  this  work  will  probably  appear  before 
the  close  of  the  present  year  (1908),  further  comment  is  unneces- 
sary.    In  the  papers  of  the  writer '  which  have  thus  far  appeared, 

'  Notes  on  a  tubercle  bacillus  having  a  low  degree  of  virulence.  Joum.  Bost.  Soc.  Med.  Sciences. 
Nov.,  i8g8.  Studies  in  mammalian  tubercle  bacilli.  III.  Trans.  Assoc.  Amer.  Physicians,  1903, 
and  Joum.  Med.  Research,  1905.  XIII,  253.  A  study  of  tubercle  bacilli  isolated  from  three  cases 
of  tuberculosis  of  the  mesenteric  lymph  nodes.  Amer.  Joum.  Med.  Sc.  1904,  Aug.  Studies  in 
mammalian  tubercle  bacilli.  IV.  Joum.  Med.  Research.  1907.  XVI,  435  (with  Mr.  Herbert  R. 
Brown).  The  reaction  curve  of  tubercle  bacilli  from  different  sources  in  bouillon  containing  different 
amounts  of  glycerin.     Journ.  Med.  Research.     1905.     XIII,  405. 


172  TUBERCULOSIS    IN    MASSACHUSETTS. 

there  have  been  studied,  in  all,  twenty-four  human,  nine  bovine, 
three  cat,  one  dog,  two  swine,  one  horse  and  one  Coati  culture. 
Among  the  twenty-four  cultures  from  man,  five  were  regarded  as 
of  bovine  origin.  Two  of  these  were  from  mesenteric  lymph  nodes, 
three  from  tonsils  and  cervical  lymph  nodes. 

In  one  of  the  papers  a  reaction  is  described  which  enables  us  to 
divide  all  tubercle  bacilli  into  two  classes:  first,  those  which  pro- 
duce a  final  alkaline  or  neutral  reaction  to  phenolphthalein  in 
glycerin  bouillon;  and  second,  those  which  produce  a  final  acid 
reaction.  Bovine  cultures  thus  far  examined  have  belonged  to 
the  first  group,  most  human  cultures  to  the  second.  Those  human 
cultures  which  belonged  to  the  first  group  possessed  also  other 
characteristics  of  the  bovine  type,  and  the  infection  of  the  cases 
was  assumed  to  be  from  the  milk. 

The  existence  of  varieties  of  the  human  tubercle  bacillus  as 
well  as  of  the  bovine  bacillus  was  observed  by  the  writer  and  by 
all  investigators  who  studied  carefully  series  of  cultures.  This 
subject  of  variation  among  tubercle  bacilli  is  reviewed  by  the 
writer  ^  in  a  general  way  in  a  short  paper  in  1899. 

The  relation  existing  between  bovine  and  human  tuberculosis 
is  one  of  great  importance  to  the  public  health,  because  of  the 
excessive  use  of  cows'  milk  in  infancy  and  in  various  states  of 
disease  and  invalidism.  The  writer  ^  summarized  the  relationship 
as  deducible  from  reports  of  investigations  in  1902  and  1907. 

In  these  papers  he  takes  a  middle  ground,  —  that  there  is  danger 
from  cows'  milk  containing  tubercle  bacilli,  but  that  the  danger 
has  been  overestimated.  Under  the  existing  conditions  he  ad- 
vises thorough  sanitary  inspection  of  dairy  herds  and  the  eliminat- 
ing of  all  cows  showing  wasting  and  any  doubtful  udder  affection. 
In  the  second  paper  arguments  drawn  from  comparative  pathology 

'  Bost.  Med.  &  Surg.  Joum.     iSgg.     Jan.  12. 

2  The  Medical  News.    1902.    LXXX,  343.     The  Bost.  Med.  &  Surg.  Joum.     1907.     CL VI I,  240. 


SMITH.  173 

and  bacteriology  are  presented  to  combat  the  theory  of  the  modi- 
fication of  the  bovine  into  the  human  type  of  tubercle  bacillus  in 
the  human  body,  and  also  the  tendency  to  regard  pulmonary 
tuberculosis  as  started  chiefly  by  bacilli  absorbed  from  the  diges- 
tive tract.  He  urges  the  need  of  more  investigation  to  clear  up 
definitely  the  controverted  points. 

Studies  on  the  morphology  of  the  tubercle  bacillus  from  human 
and  bovine  sources  were  published  by  S.  B.  Wolbach  and  Harold 
C.  Ernst.'  By  planting  cultures  on  a  variety  of  media,  and  exam- 
ining at  different  intervals  of  time,  they  came  to  the  following 
summary :  — 

1.  The  tubercle  bacillus  undergoes  marked  changes  in  morphology  with  change 
of  culture  medium. 

2.  The  microscopic  characteristics  of  a  fully  developed  culture  are  fairly  con- 
stant for  each  medium. 

3.  Growth  for  several  generations  on  a  given  medium  has  not  tended  to  impart 
fixed  characteristics,  the  change  in  form  being  just  as  prompt  and  complete  as  when 
transferred  after  a  single  generation. 

4.  These  changes  cannot  be  explained  by  assuming  that  the  sole  difference  is 
in  the  favorability  of  the  medium  for  the  growth  of  the  tubercle  bacillus.  Both 
Dorset's  egg  medium  and  the  brain  medium  must  be  classed  as  extremely  favor- 
able ones;  growth  on  each  appears  at  about  the  same  time  and  progresses  about 
equally  rapidly.  The  reaction  of  the  medium  also  does  not  explain  these  changes, 
as  the  different  media  may  have  precisely  the  same  reaction  and  yet  these  changes 
occur. 

5.  The  greatest  variations  in  form  and  staining  reaction  are  found  in  rapidly 
growing  cultures,  and  we  agree  with  Coppen-Jones  in  regard  to  the  conditions 
best  suited  for  the  production  of  branched  and  filiform  forms,  namely,  a  favorable 
medium  and  free  access  to  oxygen. 

6.  The  only  interpretation  of  the  great  diversity  of  form  assumed  by  the  tubercle 
bacillus  when  grown  under  the  most  favorable  conditions  is  that  it  is  truly  pleo- 
morphic, and  should  be  classed  among  the  higher  bacteria. 

A  similar  investigation  was  made  by  the  writer'  chiefly  for  the 
purpose  of  finding  additional  methods  for  distinguishing  the  human 

'  Joum.  Med.  Research.     1903.     X,  313.     13  plates. 

•  Trans.  Nat'l  Assoc,  for  the  Study  and  Prevention  of  Tuberculosis.     1905.     I,  211. 


174  TUBERCULOSIS    IN    MASSACHUSETTS. 

from  the  bovine  type  of  bacilli.  The  impulse  to  the  study  was 
given  by  the  change  in  the  form  of  bovine  tubercle  bacilli  observed 
in  impure  cultures.  As  soon  as  the  culture  was  purified  the  bacilli 
assumed  their  original  short  form.  The  probable  explanation  of 
the  phenomenon  observed  is  the  softening  and  increased  stickiness 
of  the  outer  layer  or  capsule  of  the  bacilli  in  the  impure  culture, 
perhaps  under  the  influence  of  some  bacterial  enzyme. 


I 


MILLET.  175 


CHAPTER   XIII. 

OUT-OF-DOOR  SLEEPING  IN  NEW  ENGLAND. 
Charles  S.  Millet,  M.D. 

The  New  England  climate  has  for  a  long  time  had  a  national 
reputation  for  insalubrity.  Its  variability  and  bleak  east  winds 
have  been  the  subject  of  much  comment,  both  by  natives  and 
visitors,  and  yet  one  of  the  most  important  steps  taken  in  the 
campaign  against  tuberculosis  since  the  discovery  of  the  tubercle 
bacillus,  namely,  out-of-door  sleeping,  had  its  origin  in  Massachu- 
setts, where  formerly  a  large  proportion  of  the  population  had 
always  been  afraid  of  out-of-door  air,  and  especially  at  night,  and 
have  attributed  their  coughs  and  colds  to  the  weather  rather  than 
to  the  true  cause.  •;  , 

In  the  winter  of  1898  the  writer  was  called  to  see  a  young  mar- 
ried man  with  an  unusual  family  history  of  tuberculosis.  His 
father,  brother,  grandfather,  two  aunts  and  an  uncle  all  had  died 
of  consumption.  He  had  been  coughing  and  losing  flesh  for  several 
weeks,  and  at  the  time  of  presenting  himself  for  examination  he 
suffered  from  coughing,  wheezing  and  shortness  of  breath  and 
nearly  every  day  had  a  temperature  of  100.5°.  There  was  no 
marked  physical  evidence  of  pulmonary  infection,  but  throughout 
the  winter,  in  spite  of  the  use  of  remedies  ordinarily  employed 
in  such  cases  he  continued  to  lose  ground.  By  spring  time  he 
had  lost  nearly  fifteen  pounds,  and  had  become  so  weak  that  he 
could  exert  himself  but  little  without  marked  dyspncea. 

On  May  2,  two  leading  specialists  saw  him  in  consultation,  and 
agreed  that  he  undoubtedly  had  pulmonary  tuberculosis,  and  they 
recommended  that  he  be  sent  to  Arizona;  one  advising  that  the 


176  TUBERCULOSIS    IN    MASSACHUSETTS. 

change  be  made  immediately,  and  the  other  suggesting  that  first 
he  might  try  the  effect  of  rest  for  a  period  of  two  months,  at  the 
end  of  which  time,  if  he  did  not  show  decided  improvement,  the 
change  should  be  made.  He  was  much  depressed  at  the  thought  of 
leaving  home,  and  very  shortly  lost  four  or  five  pounds  more.  A 
short  time  afterwards  a  paper  on  the  foreign  sanatoria  for  the 
treatment  of  tuberculosis  was  given  in  Boston,  with  stereopticon 
views,  and  the  writer  was  much  impressed  by  the  difference  in  the 
manner  of  treatment  of  disease  in  this  country  and  in  Germany; 
and  that  which  made  the  deepest  impression  was  the  statement 
that  Detweiller,  of  Gorbersdorf,  kept  his  patients  up  late  at  night, 
in  order  to  increase  the  number  of  hours  spent  in  the  open  air. 
This  suggested  the  thought  that,  inasmuch  as  consumptives  need 
their  night's  rest  fully  as  much  as  pure  air,  it  might  be  of  advantage 
to  sleep  out  of  doors;  and  on  the  following  day  the  patient  was 
asked  if  he  would  make  the  experiment,  and  was  assured  that  if 
he  agreed,  nothing  more  would  be  said  about  being  sent  away  from 
home.  He  accepted  the  plan,  and  proceeded  to  erect  a  platform 
on  the  south  side  of  his  house.  He  began  sleeping  there  in  the 
latter  part  of  June,  1898,  and  during  the  next  five  months  passed 
every  night  there,  with  the  exception  of  nine,  when  he  was  pre- 
vented from  doing  so  by  rain.  Within  the  first  two  weeks  im- 
provement was  evident,  and  at  the  end  of  a  month  his  temperature 
was  normal  at  all  times  of  the  day,  his  coughing  and  wheezing  had 
nearly  disappeared  and  he  seemed  to  be  on  the  road  to  recovery. 
At  Thanksgiving  time  his  weight  was  one  hundred  and  forty-four 
pounds,  —  a  gain  of  twenty-two  pounds  in  five  months;  and  at 
the  present  time  he  weighs  one  hundred  and  forty-seven.  He 
has  been  perfectly  free  from  pulmonary  symptoms  during  all  this 
time. 

During  the  months  of  his  experiment  he  worked  nine  hours  a 
day  four  days  in  the  week  in  a  shoe  factory,  situated  in  the  same 
town,  which  is  twelve  miles  from  the  seacoast  and  but  one  hundred 


I 


MILLET. 


177 


feet  above  sea  level.  He  wore  at  night  a  soft  felt  hat  and  cotton 
night  shirt,  and  was  covered  with  the  ordinary  bed  clothes.  He 
went  to  bed  usually  before  nine  o'clock,  because  the  sun  awakened 
him  very  early  in  the  morning. 

The  result  of  the  experience  with  this  patient  led  to  the  conclu- 
sion that  this  must  be  the  proper  way  to  treat,  not  only  tubercu- 
losis, but  all  pulmonary  diseases,  since  if  an  abundance  of  fresh 
air  is  good  for  chronic  pulmonary  complaints,  it  ought  to  be  quite 
as  beneficial  in  acute  complaints  as  well.  In  consequence,  during 
the  next  winter  every  case  of  pneumonia  which  came  under  the 
writer's  care  was  treated  in  a  room  with  wide-open  windows, 
regardless  of  the  age  of  the  patient.  Even  a  child  eighteen  months 
old  was  placed  close  to  an  open  window  in  March  when  the  wind 
was  blowing  a  gale.  During  the  summer  of  1899,  seven  additional 
patients  were  induced  to  sleep  out-of-doors. 

It  has  been  well  said  that  the  importance  of  out-door  sleeping 
in  the  treatment  of  tuberculosis  can  scarcely  be  overestimated, 
and  it  has  been  the  writer's  experience  that  one  can  obtain  far 
more  rest  out  of  doors  in  six  hours  than  indoors  in  eight.  The 
following  are  the  closing  words  of  a  paper  read  by  the  writer 
nine  years  ago,  and  they  are  reproduced  here  because  they  are  still 
believed  to  be  true,  although  neither  the  profession  nor  the  public 
has  as  yet  fully  accepted  them:  — 

One  word  about  those  cabalistic  terms  "dampness"  and  "draughts."  They 
are  bugbears,  that  is  all,  and  need  not  be  considered  for  a  moment.  Many  times 
these  patients  have  found  their  bed  coverings  and  night  clothes  wet  with  dew, 
and  once  in  a  while  a  summer's  rain  has  disturbed  their  healthful  slumbers,  but 
with  no  harm,  beyond  the  necessity  of  drying  the  bed-clothes  before  they  are 
again  used. 

I  am  quite  ready  to  believe  that,  if  people  could  be  taught  to  fear  impure  air 
and  overheated  rooms  as  they  now  dread  a  slight  increase  of  moisture  or  a  little 
air  stirring,  tuberculosis  would  become  nearly  as  infrequent  as  small-pox. 

In  the  spring  of  1900,  a  small  sanatorium  was  opened  at  East 
Bridgewater,  in  order  to  emphasize  still  further  the  importance 


iy8  TUBERCULOSIS    IN    MASSACHUSETTS. 

of  method  over  climate  in  the  treatment  of  consumption,  and 
here  was  first  built  the  shack  which  is  now  so  frequently 
brought  into  play  in  fighting  this  disease.  Their  use  is  now  so 
common,  both  in  sanatoria  and  when  applying  the  treatment  at 
home,  that  a  description  of  what  is  considered  ideal  in  this  respect 
may  be  of  interest.  By  indefinitely  multiplying  the  units,  of 
which  the  shack-room  herein  described  is  one,  a  large  shack  or 
ward  can  be  constructed  so  as  to  give  a  maximum  amount  of  sun 
and  air  at  a  minimum  cost. 

THE   SHACK. 

Theoretically,  the  shack,  properly  designed,  is  the  ideal  con- 
struction for  housing  tuberculous  patients.  In  it  the  sufferer  is 
constantly  surrounded  by  the  purest  air,  without  a  chance  of 
contamination  or  stagnation,  and  he  and  everything  about  him  is 
exposed  all  day  and  every  day  to  the  curative  and  vivifying  in- 
fluences of  the  sunshine.  In  a  large  institution  the  extra  cost  of 
attendance  upon  patients  in  separate  shacks  may  be  a  serious 
item,  but  even  in  such  establishments  some  shacks  are  needed  for 
patients  whose  symptoms  require  the  conditions  which  can  be 
provided  only  in  them.  For  those  persons  who,  under  proper 
advice,  undertake  their  own  cure,  they  are  infinitely  preferable  to 
the  tents  commonly  used. 

The  shack  for  tuberculous  patients  must  have  all  the  air  and 
sun  which  can  possibly  be  admitted  to  it,  and  proper  shelter  from 
rain,  snow  and  violent  winds  must  be  provided.  For  this  purpose 
it  should  face  the  south;  the  front  should  be  as  open  as  possible, 
and  much  higher  than  the  back,  so  that  the  sun's  rays  may  reach 
all  parts  of  the  interior.  There  should  be  openings  on  all  the 
other  sides,  to  give  cross-currents  of  air,  although  all  the  openings 
except  those  towards  the  south  should  have  provision  for  closing 
them  in  cold  or  stormy  weather.     Even  the  south  openings  should 


MILLET.  179 

have  screens  of  some  sort,  for  protection  against  southerly  rains, 
but  they  need  not  often  be  brought  into  use.  If  the  shack  is  near 
a  dwelHng-house  or  administration  building  which  the  patient  can 
easily  reach,  nothing  more  than  a  simple  structure,  twelve  feet 
square,  with  four  walls,  a  floor  and  roof,  standing  on  posts,  and 
costing  about  $100  complete,  will  be  required;  but  for  greater 
comfort,  especially  for  patients  unable  to  walk  far,  a  dressing 
room,  which  will  double  the  cost,  may  be  added,  as  shown  in  the 
accompanying  plan  and  photograph  of  one  of  the  latest  shacks 
attached  to  the  Millet  Sanatorium  at  East  Bridgewater.  This 
building  is  twelve  by  eighteen  feet,  supported  on  cedar  posts, 
boarded,  and  the  sides  and  roof  shingled.  It  faces  due  south,  and 
the  roof  rises  toward  the  front  at  an  angle  of  twenty-six  and  one- 
half  degrees,  known  to  builders  as  a  "  quarter  pitch."  The  interior 
is  divided  into  a  bedroom  twelve  feet  square  and  a  dressing  room 
six  by  twelve  feet.  The  front  of  the  bedroom  is  entirely  open. 
Sashes  can  be  fitted  into  the  spaces  between  the  posts  if  necessary, 
but  experience  shows  that  they  are  not  required,  light  screens, 
covered  with  paraffined  cloth,  having  been  found  sufficient  to  ex- 
clude rain  and  snow.  These  screens  are  hinged  to  the  top  of  the 
openings,  and  are  drawn  up  to  the  under  side  of  the  roof  when  not 
in  use.  The  north  wall  of  the  bedroom  is  about  six  and  one-half 
feet  high,  and  has  three  openings,  which  can  be  closed  in  bad 
weather  by  means  of  hinged  wooden  shutters.  Toward  the  west 
is  a  door  to  the  outside  and  a  window,  and  on  the  east  is  the  sliding 
door  leading  into  the  dressing  room,  which  has  a  window  opposite 
the  door  and  also  a  south  window.  In  the  dressing  room  is  a 
chimney  and  a  stove,  a  set  wash-basin  with  running  water,  and  a 
water-closet,  together  with  movable  bureau  and  wardrobe.  In 
pleasant  weather  the  windows  and  door  of  the  dressing  room  are 
kept  open ;  in  cold  weather  they  are  closed,  so  that  the  water  pipes 
may  not  freeze.    The  bedroom  openings  are  practically  never 


l80  TUBERCULOSIS    IN    MASSACHUSETTS. 

closed.  With  the  exception  of  the  chimney,  the  whole  construc- 
tion is  of  wood.  There  is  no  plastering,  the  partitions  being  of 
wood  sheathing.  The  floor  is  double,  the  upper  floor  being  a 
narrow  rift  North  Carolina  pine.  The  cost  of  this  structure,  which 
is  one  of  two  exactly  alike,  was  $300.  To  one  who  has  not  been 
long  familiar  with  the  treatment  of  tuberculosis  in  shacks  of  this 
kind,  the  comfort  and  pleasure  which  the  patients  find  in  them  is 
incredible.  Even  with  the  thermometer  at  zero,  or  below,  they 
do  not  wish  to  close  the  openings;  and  it  is  found  that  they  gain 
more  rapidly  in  the  winter  than  during  the  milder  seasons  of  the 
year. 


SEDGWICK  —  MacNUTT.  i8i 


CHAPTER   XIV. 

ON  AN  APPARENT  CONNECTION  BETWEEN  POLLUTED  PUB- 
LIC WATER  SUPPLIES  AND  THE  MORTALITY  FROM 
PULMONARY  TUBERCULOSIS. 

William  T.  Sedgwick,  Ph.D.,  and  Scott  MacNutt,  S.B. 

In  the  course  of  a  statistical  investigation  recently  made  by  us 
of  Hazen's  theorem,  that  for  every  death  from  typhoid  fever 
avoided  by  the  purification  of  polluted  water  supplies  two  or  three 
deaths  are  avoided  from  other  causes,'  we  have  been  led  to  the 
conclusion  that  among  these  "other  causes"  pulmonary  tubercu- 
losis holds  an  important  place.  We  are  well  aware  that  tuber- 
culosis is  not  generally  regarded  as  water-borne,  and  we  have 
ourselves  been  surprised  to  find  any  evidence  of  an  apparently 
positive  connection  of  some  sort  between  mortality  from  pul- 
monary tuberculosis  and  polluted  public  water  supplies.  Our 
inquiries  obliged  us  to  study  with  care  the  vital  statistics  of  the 
cities  of  Lawrence  and  Lowell,  Mass.,  immediately  before  and 
after  each  of  these  began  to  supply  its  citizens  with  water  very 
much  purer  than  that  previously  furnished,  and  also  to  compare 
the  statistics  of  each  with  those  of  the  other,  and  of  both  with 
those  of  a  third  city,  Manchester,  N.  H.,  of  the  same  general 
character  and  similarly  situated,  but  supplied  during  the  same 
periods  with  a  pure  upland  water  drawn  from  a  large  lake.  In 
order  to  show  the  basis  of  our  comparisons  and  conclusions,  it  will 
be  necessary  to  explain  in  some  detail  the  way  in  which  these 
developed  during  our  studies. 

It  was  observed  some  years  ago,  first,  apparently,  by  Mr.  Hiram 
F.  Mills,  the  eminent  engineer  and  member  of  the  State  Board  of 


'  Science.    August  7,  1908. 


l82  TUBERCULOSIS    IN    MASSACHUSETTS. 

Health  of  Massachusetts,  and  by  Dr.  J.  J.  Reincke  of  Hamburg, 
Germany,  that  after  the  purification  of  a  polluted  public  water 
supply  a  decline  occurs  in  the  general,  or  total,  death-rate  of  the 
community  using  the  water,  considerably  greater  than  can  be 
accounted  for  by  the  saving  in  typhoid  fever  mortality  alone. 
This  fact  has  been  quantitatively  expressed  by  Mr.  Allen  Hazen, 
the  well-known  sanitary  engineer,  in  the  theorem  to  which  we 
have  connected  his  name,  as  stated  above.  No  one,  however,  as 
far  as  we  know,  has  hitherto  minutely  analyzed  the  decline  re- 
ferred to,  or  undertaken  to  discover  by  careful  statistical  studies 
exactly  in  what  "other  causes"  of  death  the  saving  consists.  This 
task  we  therefore  set  before  ourselves,  and  a  preliminary  communi- 
cation giving  our  principal  results  has  already  appeared  in  "Sci- 
ence" for  July  31,  1908.  It  will  suffice  for  our  present  purposes 
to  state  that  we  found  the  most  marked  improvement  so  far  as 
other  causes  of  death  were  concerned  to  reside  in  pneumonia,  pul- 
monary tuberculosis  and  infant  mortality,  and  that  we  were  forced 
to  conclude  that  some  connection  certainly  exists  between  polluted 
drinking  water  and  each  and  all  of  these. 

Lowell  and  Lawrence  are  among  the  most  prominent  of  the 
manufacturing  cities  of  Massachusetts.  They  are  situated  in  the 
valley  of  the  Merrimack  River,  only  nine  miles  apart.  Until  1893, 
both  were  supplied  with  drinking  water  drawn  directly  and  without 
any  attempt  at  purification  from  the  river  at  their  doors.  In  the 
autumn  of  that  year  Lawrence  began  to  use  a  municipal  (slow 
sand)  filter,  the  first  of  its  kind  in  America,  which  was  designed 
by  Mr.  Mills,  then  a  resident  of  that  city.  In  1896,  Lowell  changed 
from  its  polluted  water  supply  to  a  pure  ground-water  supply 
derived  from  driven  wells  located  not  far  from  the  Merrimack 
River.  In  both  cases  the  improvement  in  typhoid  fever  mortality 
was  immediate  and  conspicuous.  And  in  both,  as  Mr.  Mills  dis- 
covered, and  as  is  now  easy  to  observe,  there  occurred  a  decline 


SEDGWICK  —  MacNUTT.  183 

in  the  general  death-rate  —  the  total  mortality  —  much  greater 
than  could  be  accounted  for  by  the  decline  in  typhoid  fever  mor- 
tality alone.  The  time,  however,  was  one  of  general  sanitary 
awakening  and  of  widespread  sanitary  improvements.  A  similar 
fall  in  the  total  death-rate  was  detected  at  Hamburg,  Germany, 
after  the  installation  of  sand  filtration  of  the  public  water  supply" 
of  the  city  subsequent  to  the  great  Asiatic  cholera  epidemic  of 
1892,  and  was  commented  upon  by  the  able  health  officer  of  Ham- 
burg, Dr.  J.  J.  Reincke,  who  was  cautiously  inclined  to  attribute 
it  chiefly,  if  not  wholly,  to  the  important  and  extensive  sanitary 
improvements  then  everywhere  common  in  Germany  and  in  Ham- 
burg especially,  because  of  the  recent  epidemic. 

In  our  complete  paper,  soon  to  be  published,  we  have  reviewed 
the  evidence  of  various  kinds  hitherto  available,  and  have  there 
made  for  ourselves  an  independent  statistical  study  of  all  the  data 
bearing  upon  the  various  causes  of  death  in  Lowell  and  Lawrence 
for  the  five  years  just  before  and  the  five  years  just  after  the  intro- 
duction of  pure  water  into  these  cities,  and  for  corresponding 
periods  at  Manchester,  N.  H.  Manchester  was  selected  as  a  norm, 
and  in  preference  to  any  city  or  cities  of  Massachusetts,  for  the 
reason  that  it  is  not  only  situated  in  the  same  (Merrimack  River) 
valley  only  a  few  miles  above  Lowell  and  Lawrence,  but  also  be- 
cause, like  them,  it  has  a  large  population  of  foreign  types,  chiefly 
French  Canadian,  engaged  for  the  most  part  in  the  same  (textile) 
industries.  These  populations  we  examined  statistically  at  the 
outset,  and  found  agreeing  to  a  remarkable  extent  in  respect  to 
age,  sex  and  nationality  distribution,  and  in  industrial  occupation. 
We  also  determined  at  the  outset  that  these  conditions  of  agree- 
ment had  remained  practically  constant  throughout  the  periods 
under  consideration,  so  that  these  sources  of  error  were  excluded 
as  possible  factors  of  diminished  death  rates.  We  were  agreeably 
surprised  to  find  in  the  three  cities  studied  a  set  of  conditions  of 


1 84 


TUBERCULOSIS    IN    MASSACHUSETTS. 


an  almost  "laboratory"  character,  making  of  Manchester  a  norm, 
or  control,  as  favorable  for  our  purposes  as  could  have  been  desired. 
Among  the  causes  of  death  considered  in  detail  was  pulmonary 
tuberculosis.  For  purposes  of  comparison,  the  total  deaths  from 
this  cause  were  compared  year  by  year  with  the  estimated  popula- 
tion, and  the  mean  death-rates  computed  for  the  five-year  periods 
just  before,  and  the  five-year  periods  just  after,  water  supply  im- 
provement in  Lowell  and  Lawrence,  respectively,  the  years  of 
actual  change  being  omitted.  For  Lowell  these  five-year  periods 
are  1889-93,  before,  and  1896- 1900,  after,  the  improvements 
having  been  introduced  during  1894  and  1895.  For  Lawrence, 
they  are  1888-92,  before,  and  1894-98,  after,  improvements  ef- 
fective in  1893.  ^ri  all  these  cases  corresponding  periods  for  com- 
parison have  been  taken  for  Manchester,  N.  H.,  in  which,  as  already 
stated,  no  material  change  has  occurred  for  many  years  in  the 
character  of  the  (pure)  public  water  supply.  The  broad  results  of 
these  comparisons  may  be  grouped  together  as  follows:  — 

Pulmonary  Tuberculosis. 

Annual  Death-rates  per  100,000  Population. 

[Five-year  periods.] 


NAME  OF 

CITY. 

Before 
Water  Supply 
Improvement. 

After 
Water  Supply 
Improvement. 

For  same  periods:  — 

Lowell,  Mass., 

288 

205 

Manchester,  N.  H., 

205 

200 

For  same  periods:  — 

Lawrence,  Mass.,  . 

244 

185 

Manchester,  N.  H., 

222 

192 

Lowell  thus  showed  a  decreased  average  annual  death-rate  from 
pulmonary  tuberculosis  for  the  five  years  following  the  introduc- 
tion of  pure  water  of  eighty-three  per  100,000  inhabitants,  while 


SEDGWICK  —  MacNUTT.  185 

Manchester  showed  a  decrease  of  only  five  per  100,000  inhabitants 
for  the  same  period.  Lawrence  showed  a  decrease  of  fifty-nine 
per  100,000  inhabitants  annually  for  the  five  years  after  improve- 
ment, while  for  the  corresponding  years  phthisis  in  Manchester 
fell  off  only  thirty  per  100,000  inhabitants  annually.  If,  as  we 
believe,  Manchester's  decline  may  be  considered  normal  for  both 
periods,  we  are  compelled  to  conclude  that  the  decline  in  Lowell 
over  and  above  what  might  have  been  expected  was  about  seventy- 
eight  per  100,000  inhabitants  yearly,  and  in  Lawrence  about 
twenty-nine  per  100,000  inhabitants.  Unquestionably,  the  pul- 
monary tuberculosis  mortality  in  both  Lowell  and  Lawrence  was 
slowly  declining  —  as  in  Massachusetts  generally  —  during  the 
periods  under  consideration.  But  it  appears  to  have  fallen  sud- 
denly, and  much  more  than  would  have  been  anticipated,  and 
much  more  than  it  actually  did  fall  in  a  nearby  city  of  closely 
similar  character  during  the  years  immediately  following  a  great 
change  for  the  better  in  the  purity  of  the  public  water  supply  of 
each  city.  These  facts,  disclosed  by  a  study  which  we  believe  to 
be  of  a  high  degree  of  statistical  accuracy,  are  certainly  striking 
and  suggestive;  and  inasmuch  as  we  have  been  unable,  even  after 
the  most  careful  investigation,  to  discover  any  other  possible  ex- 
planation of  them,  we  are  forced  to  the  conclusion  that  a  consider- 
able portion  of  the  decline  in  mortality  from  tuberculosis  in  Lowell 
and  Lawrence  during  the  year  immediately  following  their  change 
from  polluted  to  pure  water  supplies  was  due  to  that  change.  In 
other  words,  polluted  public  water  supplies  appear  to  increase  the 
general  mortality  of  communities  from  tuberculosis;  pure  water 
supplies  to  diminish  that  mortality. 

Dr.  Reincke,  in  discussing  the  effects  of  purification  of  the  public 
water  supply  of  Hamburg  by  the  sand  filters  introduced  in  1893 
upon  the  mortality  from  specific  causes,  noted  among  other  things 
a  marked  decrease  in  mortality  from  diseases  of  the  respiratory 


l86  TUBERCULOSIS    IN    MASSACHUSETTS. 

organs,  including  pulmonary  tuberculosis.  For  years  the  tuber- 
culosis mortality  had  been  declining  in  Hamburg,  it  continued 
to  decline  after  installation  of  the  sand  filters,  and,  as  is  now  in- 
teresting to  note,  at  a  somewhat  greater  rate.  Dr.  Reincke,  how- 
ever, expressly  avoided  attributing  any  of  the  decline  in  tubercu- 
losis to  the  purification  of  the  public  water  supply,  preferring  rather 
to  look  for  its  cause  in  those  general  improvements  in  the  sanitary 
conduct  of  life  in  which  the  time  abounded,  and  which  were 
naturally  most  to  be  expected  in  a  city  like  Hamburg,  just  recover- 
ing from  a  disastrous  epidemic  of  Asiatic  cholera.  For  us,  on  the 
other  hand,  when  taken  in  connection  with  the  phenomena  in 
Lowell  and  Lawrence,  this  decline  in  tuberculosis  mortality  in 
Hamburg,  which  was  comparatively  sudden  and  rapid  after  fil- 
tration began,  takes  on  another  meaning;  and  we  cannot  escape 
the  conclusion  that  it  was  caused,  in  some  small  part,  at  least,  by 
the  purification  of  a  previously  polluted  water  supply.  Further 
evidence  pointing  in  the  same  direction  will  be  given  in  our  com- 
plete paper,  and  therefore  need  not  be  recited  here. 

If  it  be  granted  that  some  connection  really  exists  between  pol- 
luted drinking  water  and  pulmonary  tuberculosis,  such  that  the 
substitution  of  a  pure  for  a  polluted  sUpply  causes  a  marked  de- 
crease in  mortality  from  that  disease,  the  question  naturally  arises. 
Is  this  decrease  due  to  diminished  infection;  or  is  it  due  to  in- 
creased vital  resistance;  or  is  it  due  to  a  co-operation  of  these 
principal  factors?  This  problem  we  have  not  yet  been  able  to 
solve  to  our  own  satisfaction. 


GETCHELL. 


187 


CHAPTER   XV. 


THE    RELATION    OF    THE    INDUSTRIES    OF    WORCESTER    TO 

TUBERCULOSIS. 

Albert  C.  Getchell,  M.D. 

Worcester  is  near  the  central  part  of  the  State,  forty-four  miles 
from  the  ocean,  and  lies  on  the  eastern  slope  of  the  uplift  of  land 
called  the  central  plateau  of  Massachusetts.  The  contour  of  the 
land  is  uneven,  the  hills  being  elevations  of  the  earth's  crust,  and 
also  glacier  formations  called  drumlins.  The  altitude  varies  from 
four  hundred  and  eighty  feet,  that  of  the  Union  Railway  Station, 
to  one  thousand  feet  within  the  corporate  limits  of  the  city.  Al- 
ready the  city  has  covered  many  hills  of  seven  hundred  feet  eleva- 
tion and  is  spreading  out  to  higher  ones.  The  estimated  popula- 
tion is  147,084. 

By  far  the  largest  number  of  manufactories  are  situated  along 
the  lines  of  these  railways,  although  several  important  ones  are  in 
other  parts  of  the  city,  even  on  the  outer  border  of  thickly  settled 
portions. 

The  industries  are  varied  in  character.  The  following  are  the 
twenty  largest.  The  estimated  number  of  employees  is  obtained 
from  the  Board  of  Trade:  — 


American  Steel  and  Wire  Company, 

Crompton  &  Knowles  Loom  Works, 

Graton  &  Knight  Manufacturing  Company  (leather  belting) 

Worcester  Corset  Company,      ..... 

United  States  Envelope  Company,    .... 

Norton  Company  (grinding  wheels), 

M.J.  Whittall  Carpet  Company,        .... 

Winslow  Skate  Company,         ..... 

Harrington  &  Richardson  Arms  Company, 


Persons  employed. 
6,000 
2,000 
1,000 
1,000 
1,000 
1,000 
1,000 


l88  TUBERCULOSIS    IN    MASSACHUSETTS. 

W.  H.  Burns  Company  (underwear),          .....  500 

George  C.  Whitney  Company  (holiday  goods  and  valentines),       .  450 

Spencer  Wire  Company,            .......  400 

F.  E.  Reed  Company  (machine  tools),        .....  375 

Heywood  Boot  and  Shoe  Company,            .....  325 

Reed   &   Prince  Manufacturing  Company   (screws,  bolts,  rivets, 

etc.) 200 

Wire  Goods  Company,     ........  200 

Coes  Wrench  Company,  ........  190 

Worcester  Machine  Screw  Company,          .                   .                   .  175 
Curtis  &  Marble  Manufacturing  Company  (cotton  and  woolen  ma- 
chinery),    .         .                            .         .         .         .         .         .110 

Besides  these  manufactories  and  others  doing  similar  work,  — 
for  many  of  these  are  dupHcated  several  times,  —  are  factories  for 
the  manufacture  of  agricultural  machinery,  machines  for  envelope 
making,  paper  making,  horse  clipping,  grinding  and  drilling, 
planers,  lathes,  steam  boilers,  engines,  elevators,  water  meters, 
turbine  water  wheels,  iron  bridges  and  construction  material,  drop 
forging,  pressed  steel,  razors,  card  clothing,  pianos,  organ  reeds, 
simplex  piano  player,  builders'  supplies,  wooden  boxes,  wall  paper, 
sewer  and  drain  pipe,  building  stone  and  a  large  number  of  mis- 
cellaneous articles. 

It  is  estimated  that  about  twenty-five  thousand  persons  are 
employed  in  the  industries  of  Worcester,  of  which  75  per  cent,  are 
males,  a  very  large  proportion  of  them  being  skilled  workmen, 
commanding  good  pay.  The  housing  of  these  operatives  is  almost 
entirely  in  private  and  not  in  corporation  houses.  The  prevailing 
style  of  house  for  the  average  workman  is  a  wooden  building, 
commonly  called  a  three-decker.  This  consists  of  three  separate 
tenements,  superimposed  one  on  the  other.  Usually  a  small  plot 
of  land  surrounds  these  houses,  and  very  large  numbers  of  them 
are  on  high  land.  The  water  supply  is  derived  from  large  reser- 
voirs in  the  high  land  west  of  the  city,  and  is  abundant  and  of  good 
quality.     The  sewage  is  treated  by  chemical  precipitation,  and 


GETCHELL. 


189 


discharged  into  a  river  emptying  into  Narragansett  Bay,  forty 
miles  away. 

In  order  to  get  an  idea  as  to  which  industries  furnish  the  largest 
number  of  tubercular  persons,  I  have  taken  a  series  of  one  thousand 
cases  which  have  come  under  my  personal  observation  during  the 
last  four  years.  Of  these,  four  hundred  and  sixteen  applied  at  the 
Worcester  office  for  examination  for  the  State  Sanatorium;  four 
hundred  and  six  are  from  the  Tuberculosis  Clinic  at  the  Worcester 
City  Hospital;  and  one  hundred  and  seventy-eight  are  from  my 
private  practice.  Not  all  of  the  first  and  third  of  these  classes 
lived  in  Worcester,  but  nearly  all  did,  and  most  of  the  others  came 
from  the  neighboring  towns.  Of  those  applying  at  the  Tubercu- 
losis Clinic,  all  must  be  residents  of  Worcester.  Of  the  first  two 
classes,  not  all  were  surely  tuberculous,  but  all  came  because  they 
were  supposed  to  be  tuberculous.  It  is  evident  no  one  would  ap- 
ply for  admission  to  the  State  Sanatorium  unless  there  were  definite 
reasons  for  supposing  he  had  tuberculosis.  No  persons  are  re- 
ceived at  the  Tuberculosis  Clinic  except  those  referred  from  other 
departments  of  the  hospital,  or  those  whom  the  admitting  officer, 
a  competent  physician,  thinks  to  be  tuberculous.  The  cases  from 
my  private  practice  I  have  gone  over  carefully,  and  have  included 
only  those  which  are  without  doubt  of  this  class.  Of  these 
thousand  cases,  seven  hundred  and  twenty-three  may  be  grouped 
into  the  following  classes,  according  to  occupation:  — 


Housewives, 

225 

Machinists  and  miscellaneous  iron  workers, 

82 

Children  and  students,  .... 

66 

Clerks, 

65 

Cotton,  woolen  and  carpet  mill  operatives, 

Domestics, 

Laborers,      ...... 

Leather  workers,  including  shoemakers,  . 

Wire  workers, 

31 

Drivers,  —  milk  wagons,  etc., 

'7 

190 


TUBERCULOSIS    IN   MASSACHUSETTS. 


Peddlers 

Carpenters,  masons  and  painters, 
Dressmakers  and  seamstresses. 
Underwear,  corset  makers,  etc.. 
Teachers,      .... 
Street  and  steam  railway  employes. 


16 
15 
15 
13 
10 
10 


1  have  made  no  note  in  this  paper  of  those  occupations  whose 
number  fell  under  ten,  except  the  following,  which  are  generally 
supposed  to  be  productive  of  consumption,  namely,  those  in  which 
a  large  amount  of  grinding  is  done.    They  are:  — 


Emery  wheel  works, 
Wrench  shop. 
Razor  factory,     . 


Skate  shop,    . 
Grinding  shops. 
Pistol  shop,   . 


It  is  to  be  noted  that,  while  grinding  is  done  in  these  factories, 
only  a  comparatively  small  number  in  each  shop  work  at  grinding. 

Mr.  James  C.  Coffey,  the  executive  officer  of  the  Board  of  Health, 
investigated  the  same  question  from  another  point  of  view.  He 
went  over  the  death  returns  of  the  year  1904,  to  determine  the 
occupations  of  those  who  died  in  that  year  from  tuberculosis, 
with  the  following  result:  — 


Laborers, 

Machinists, 

Clerks, 

Wire-workers, 

Students, 

Shoemakers, 

Carpenters, 

Teamsters, 

Leather  workers. 

Mill  operatives, 

Dressmakers, 

Grocers,    . 

Barbers,    . 

Bar-tenders, 

Moulders, 

Printers,   . 

Polishers, 


46 

Painters, 

45 

Stone-cutters, 

41 

Masons, 

28 

Plumbers, 

21 

Saleswomen, 

16 

Teachers,   . 

>4 

Armorers,  . 

•3 

Agents, 

10 

Cooks, 

10 

Domestics, 

9 

Farmers,    . 

9 

Gardeners, 

8 

Nurses, 

7 

Porters, 

7 

Screw-workers 

7 

Wood-workers 

7 

GETCHELL.  I9I 

The  figures  of  these  two  groups  of  cases  pointed  to  no  definite 
industry  as  productive  of  tuberculosis.  Still,  in  order  to  investi- 
gate the  question  more  directly,  I  visited  personally  most  of  the 
largest  plants  and  many  of  the  smaller  ones.  I  was  given  every 
opportunity  to  thoroughly  inspect  them,  in  several  instances  my 
guide  being  the  superintendent  of  the  place.  I  found  the  owners 
of  the  mills  and  superintendents  generally  interested  in  the  sub- 
ject, and  in  some  instances  particularly  so.  The  hygienic  character 
of  the  buildings  varied  directly  with  their  age,  the  newer  ones 
being  always  better,  —  in  many  instances  models  of  proper  mill 
construction.  Some  of  the  plants  were  the  growth  of  more  than 
half  a  century.  In  one  of  them  I  was  shown  a  room  in  which  the 
old  overshot  wheel  was  first  installed,  still  used  for  manufacturing 
purposes,  —  a  dark,  ill-ventilated  room.  I  particularly  inspected 
all  factories  in  which  either  wet  or  dry  grinding  is  done.  In  some 
of  the  factories  the  grinding  was  done  in  large,  light,  above-ground 
rooms;  in  others,  in  darker  basements.  But  everywhere  I  found 
an  efficient  system  of  exhaust  pipes,  through  which  the  dust  of  the 
grinding  was  removed,  and  the  air  in  the  vicinity  of  the  grinding 
machines  was  apparently  as  free  from  dust  as  that  in  other  parts  of 
the  same  factory.  The  foremen  of  these  factories  talked  very 
freely  with  me  about  consumption  among  their  employees,  and 
from  their  experience,  as  well  as  from  my  own  investigations,  I 
could  not  attribute  to  grinding  a  causative  factor.  In  these  visits 
I  was  impressed  with  the  care  taken  to  keep  the  factories  clean; 
in  some  places  men  or  boys  were  constantly  employed  sweeping 
the  floors  and  removing  the  dirt. 

The  histories  of  the  thousand  cases  which  form  the  basis  of  this 
paper  were  taken  on  similar  printed  forms.  One  of  the  questions 
related  to  the  source  of  infection.  Personally,  this  subject  has 
very  much  interested  me,  and  I  have  laid  stress  upon  it  in  exam- 
inations. But  I  can  recall  only  one  instance  in  which  an  operative 
thought  he  contracted  the  disease  at  his  work.    That  was  an  op- 


192  TUBERCULOSIS    IN    MASSACHUSETTS. 

erative  in  a  hat  shop,  who  said  that  a  fellow  workman  had  had  a 
cough  for  some  time  and  freely  spat  on  the  floor. 

From  this  study  my  conclusions  are  that  no  industry  in  Worces- 
ter stands  in  any  particular  causative  relation  to  tuberculosis. 
If  it  shows  anything,  it  emphasizes  the  belief  that  the  disease  im- 
plants itself  in  the  home;  that  it  develops  most  readily  in  those 
who  follow  a  sedentary  life  (note  the  large  number  of  clerks  and 
students) ;  that  it  occurs  more  often  in  the  unskilled  workman, 
who  earns  small  wages,  and  consequently  cannot  house  and  feed 
himself  adequately. 

There  can  be  no  question  that  certain  occupations  are  worse  for 
the  already  tuberculous  than  others;  and  there  can  be  no  question 
as  to  the  duty  of  the  community  to  insist  that  all  work  places  be 
as  healthy  as  the  requirements  of  the  particular  industry  will 
allow,  that  the  well  may  keep  well,  and  that  those  predisposed  to 
tuberculosis  or  having  the  disease  may  not  be  so  weakened  by  un- 
hygienic surroundings  that  they  will  succumb  to  it. 

An  efficient  campaign  against  tuberculosis  means  clean  streets, 
clean,  light  and  well-ventilated  stores,  offices,  public  places, 
schools  and  factories;  but  in  this  community  at  least,  we  must 
look  to  the  home  as  the  main  breeding-place  of  the  disease,  and  it 
is  upon  the  home  that  we  must  concentrate  our  main  energies  for 
its  extermination. 


GORDON. 


'93 


CHAPTER   XVI. 

TUBERCULOSIS  AMONG  THE  GRANITE  WORKERS  OF  QUINCY. 

John  A.  Gordon,  M.D. 

It  has  long  been  recognized  that  the  proportion  of  deaths  from 
pulmonary  tuberculosis  among  the  granite  workers  of  Quincy 
was  relatively  very  large;  but  it  was  not  until  a  careful 
investigation  of  the  vital  statistics  of  the  city  was  made  that  the 
extent  of  the  disease  became  fully  evident. 

For  twenty  years  there  have  been  on  an  average  twenty-five 
hundred  men  employed  in  the  Quincy  granite  works.  Of  these, 
about  five  hundred  are  quarry  men,  twelve  hundred  granite  cut- 
ters, three  hundred  polishers,  one  hundred  and  fifty  paving 
cutters,  and  the  remainder  are  made  up  of  tool  sharpeners, 
boxers,  teamsters,  carriers  and  others  whose  occupation  is  inci- 
dental to  the  business. 

In  this  report  only  the  causes  of  death  among  the  granite  cutters, 
quarry  men  and  paving  cutters  will  be  considered,  as  it  was  found 
that  the  causes  of  death  among  polishers,  sharpeners,  boxers, 
teamsters  and  carriers  are  essentially  the  same  as  among  men 
employed  in  other  occupations. 

On  careful  examination  of  the  records  of  death  in  Quincy  for  the 
ten  years,  i.e.,  from  1897  to  1906  inclusive,  it  was  shown  that  the 
total  number  of  deaths  among  granite  cutters  from  all  causes  was 
two  hundred  and  three,  of  which  ninety-three,  or  46  per  cent., 
were  from  tuberculosis.    The  average  age  was  fifty-nine. 

The  following  table  shows  the  relation  of  the  number  of  deaths 
from  tuberculosis  to  the  total  number  of  deaths  among  granite 
cutters  by  years  for  the  same  period:  — 


194 


TUBERCULOSIS    IN   MASSACHUSETTS. 


^.T,                                           \ 

Total  Number 

Total  Number 
of  Deaths  from 

Percentage  of 
Total  Number  of 

YEAR. 

of  Deaths 
from  All  Causes. 

All  Forms 
of  Tuberculosis. 

Deaths  due 
to  Tuberculosis. 

■897 

'9 

9 

47 

1898, 

26 

10 

38 

1899, 

20 

6 

30 

1900, 

17 

10 

59 

19OI, 

23 

12 

52 

1902, 

23 

9 

39 

1903, 

18 

7 

39 

1904. 

'7 

1 1 

65 

1905, 

25 

10 

40 

1906, 

■5 

9 

60 

203 

93 

46 

Of  these  ninety-three  deaths  from  tuberculosis,  forty-six,  or 
nearly  50  per  cent.,  occurred  between  the  ages  of  forty  and  sixty, 
as  will  be  seen  from  the  following  table:  — 


AGE. 

Number  of  Deaths. 

Under  20, 

20-30, 

30-40, 

40-50, 

50-60, 

60-70, 

Over  70,    . 

2 
II 

>3 

23 
23 
18 

3 

93 

Twelve  deaths  occurred  among  the  paving  cutters,  of  which  five, 
or  41.5  per  cent.,  were  due  to  tuberculosis,  and  the  average  age 
was  fifty-four  years. 

Nine,  or  22.5  per  cent.,  of  the  forty  deaths  among  the  quarry 
men  were  due  to  tuberculosis.  The  average  age  was  forty-eight. 
The  largest  proportion  of  deaths  from  tuberculosis,  or  15  per  cent. 


GORDON.  195 

of  the  whole  number,  occurred  between  the  ages  of  forty-five  and 
fifty  years. 

The  number  of  deaths  from  tuberculosis  among  the  polishers, 
boxers  and  tool  sharpeners  averaged  only  about  1 5  per  cent.,  and 
is  essentially  the  same  as  that  from  tuberculosis  in  other  occupa- 
tions found  in  Quincy. 

The  whole  number  of  deaths  in  Quincy  during  the  above-men- 
tioned period,  i.e.,  the  years  1897  to  1906  inclusive,  was  four  thou- 
sand two  hundred.  Of  these,  but  four  hundred  and  fifty-four, 
or  1 1  per  cent.,  were  from  tuberculosis.  If  we  deduct  the  fourteen 
hundred  deaths  in  children  under  five  years  from  this  number,  very 
few  of  which  were  from  tuberculosis,  leaving  twenty-eight  hundred 
deaths  in  persons  over  five  years  of  age,  in  ten  years  we  get  an 
average  death-rate  from  tuberculosis  which  is  only  16  per  cent,  of 
the  total  death-rate.  It  will  thus  be  seen  that  the  number  of 
deaths  from  tuberculosis  among  granite  cutters  and  quarrymen 
is  relatively  very  large. 

It  is  interesting  to  note  that  in  the  two  hundred  and  fifty-five 
deaths  among  granite  cutters,  quarrymen  and  paving  cutters, 
eighteen,  or  7  per  cent.,  were  from  pneumonia,  and  fifty-four,  or 
21  per  cent.,  were  from  disease  of  the  circulatory  system  (heart 
disease,  thirty-six;  arterio-sclerosis,  seven;  apoplexy,  eleven). 

In  my  experience  of  thirty-seven  years  among  the  granite  cutters 
of  Quincy  I  have  found  that  a  large  number  were  affected  with 
chronic  bronchitis  and  emphysema,  and  in  almost  all  cases  the 
bronchitis  preceded  the  development  of  tuberculosis  by  a  consider- 
able period. 

There  is  one  feature  which  somewhat  lessens  the  serious  aspect 
of  the  condition  under  consideration.  The  deaths  from  tubercu- 
losis occurred  generally  somewhat  late  in  life,  differing  materially 
in  that  respect  from  the  usual  history  of  the  disease.  But  it  is 
deplorable,  inasmuch  as  in  nearly  50  per  cent,  of  the  cases  the  men 


196  TUBERCULOSIS   IN  MASSACHUSETTS. 

were  infected  during  the  active  working  period  of  life,  and  at  an 
age  when  their  time  is  most  valuable. 

in  investigating  the  causes  of  this  large  proportion  of  deaths 
from  tuberculosis  among  the  granite  workers  of  Quincy,  it  is  im- 
portant to  examine  the  peculiar  conditions  attending  the  quarrying 
and  cutting  of  granite  as  carried  on  at  the  present  time.  The 
granite  from  these  quarries  is  a  syenite,  consisting  of  quartz, 
felspar  and  hornblend,  with  an  occasional  mixture  of  mica,  and  is 
in  consequence  very  hard,  cutting  with  difficulty.  The  granite 
is  quarried  by  drilling  holes  in  the  face  or  surface  of  the  rock  about 
one  and  one-half  inches  in  diameter  and  several  feet  deep.  These 
holes  are  charged  with  powder,  which,  when  exploded,  breaks  off 
large  masses  of  the  rock.  These  masses  are  subdivided  into  blocks 
by  drilling  smaller  holes  in  them  and  splitting  with  ingeniously 
devised  wedges  inserted  in  these  holes.  The  drill  for  the  large 
holes  is  a  steel  bar  one  and  one-quarter  inches  in  diameter,  with 
a  flat  cutting  point.  It  is  operated  by  two  men.  One  man  holds 
the  drill  and  turns  it  about  in  the  hole,  while  the  other  man  hits 
it  on  the  head  with  a  heavy  sledge  hammer.  Every  blow  forces 
from  the  hole  a  quantity  of  fine  dust  from  the  disintegrated  granite, 
which  is  liable  to  be  inhaled  by  the  man  who  holds  the  drill.  The 
smaller  holes  are  drilled  by  one  man,  who  holds  and  turns  the  drill 
with  his  left  hand  while  he  hits  it  with  a  heavy  hammer  held 
in  his  right.  This  also  sets  free  a  large  quantity  of  fine  dust. 
In  many  cases  these  drills  are  worked  by  compressed  air,  when  a 
much  larger  amount  of  dust  is  produced.  In  most  cases  the 
quarries  are  from  twenty-five  to  a  hundred  and  fifty  feet  deep, 
and,  as  there  is  no  air  stirring,  the  quarrymen  are  almost  constantly 
enveloped  in  a  cloud  of  this  fine  dust. 

The  cutting  sheds  where  the  granite  is  finished  are  built  about 
a  semi-circular  or  rectangular  yard,  usually  of  boards,  with  a  tight 
roof  to  keep  out  the  rain.     They  are  from  twenty  to  thirty  feet 


GORDON.  197 

wide  and  about  twenty  feet  high,  and  vary  in  length  according  to 
the  size  of  the  yard  and  the  number  of  men  employed.  Each  man 
has  a  ground  space  of  about  fifty  square  feet.  There  are  doors 
along  the  front  and  back  of  these  sheds  about  eight  feet  high, 
which  can  be  raised  or  lowered  by  pulleys.  Some  of  the  sheds 
have  closed  windows  in  the  walls  above  these  doors,  others  have 
ventilators  of  slanting  boards  along  the  ridge  pole.  These  venti- 
lators are  of  little  use,  however,  in  removing  the  dust.  In  the 
very  hot  season  the  front  and  back  doors  are  usually  open,  and 
there  may  be  a  current  of  air  in  the  sheds.  In  cold  or  windy 
weather  the  back  doors  are  usually  shut,  and  in  the  winter  season 
both  front  and  back  doors  are  kept  closed  and  the  sheds  heated 
by  stoves.  In  this  case  the  sheds  are  always  full  of  dust.  The 
workmen  are  frequently  exposed  to  draughts  not  sufficiently 
strong  to  carry  off  the  dust,  yet  sufficient  to  chill  the  body  after 
perspiring. 

The  blocks  of  granite  are  brought  into  proper  shape  and 
trimmed  by  clipping  off  the  superfluous  parts  with  a  sharp- 
pointed  chisel  and  heavy  mallet.  They  are  then  finished  or  cut 
with  the  bush  hammer,  which  consists  of  a  handle  about  two 
feet  long  and  a  head  made  up  of  from  three  to  twelve  blades  of 
hard  steel  two  and  one-half  to  three  inches  square,  with  one  side 
double-bevelled  to  a  cutting  edge.  These  are  bolted  together  to 
the  head  of  the  hammer  so  as  to  form  parallel  grooves  on  the  cut- 
ting face.  By  hitting  the  block  of  granite  with  these  bush  ham- 
mers the  surface  is  gradually  disintegrated  and  thrown  off  in  the 
form  of  a  very  fine,  almost  impalpable  powder,  which  floats  about 
the  cutter  in  the  form  of  a  cloud  of  fine  dust.  It  is  inevitable 
that  the  dust  should  be  inhaled  with  every  breath.  In  some 
cases  the  bush  hammer  is  operated  rapidly  by  compressed  air, 
and  in  these  cases  a  still  greater  amount  of  dust  is  produced. 
The  particles  of  dust  are  very  fine  and  float  in  the  air  for  a  con- 


198  TUBERCULOSIS   IN   MASSACHUSETTS. 

siderable  time.  When  seen  under  the  microscope  they  present 
the  appearance  of  elongated  flattened  masses,  with  numerous 
sharp  angles  and  pointed  spiculae.  The  injurious  effects  of  the 
constant  inhalation  of  the  pulverized  granite  on  the  lung  tissue  is 
well  known. 

The  granite  cutter  usually  works  in  a  stooping  posture,  with  the 
upper  part  of  the  body  bent  over  the  stone;  and  this  position 
seriously  interferes  with  the  breathing  capacity  of  the  chest.  This 
is  particularly  the  case  with  the  letter  cutters  and  carvers,  who 
have  to  look  closely  at  their  work. 

We  find,  then,  that  the  granite  worker  is  exposed  to  three  peculiar 
conditions:  dust  of  a  particularly  irritating  character;  constrained 
position  of  the  upper  part  of  the  body;   and  excessive  draughts. 

The  determining  factors  in  the  development  of  tuberculosis  are 
the  state  of  health  and  the  susceptibility  of  the  individual,  the 
vulnerability  of  the  lungs  and  the  duration  and  intensity  of  the 
exposure  to  the  dust  and  abnormal  posture. 

The  remedy  is  difficult  to  apply,  but  not  impossible.  We  must 
first  inaugurate  a  crusade  of  enlightenment  in  the  matter.  It  is 
found,  generally,  that  the  granite  manufacturers  and  the  granite 
workers  themselves  are  very  unwilling  to  believe  that  the  occu- 
pation is  extra-hazardous,  or  that  the  dust  is  a  dangerous  element. 
If  the  facts  were  brought  forcibly  to  their  minds,  there  is  every 
reason  to  believe  that  both  the  manufacturers  and  the  workmen 
would  voluntarily  do  a  great  deal  to  ameliorate  the  condition  under 
which  the  work  is  done.  In  the  first  place,  larger  and  better  ven- 
tilated sheds  should  be  provided,  so  that  each  workman  would 
have  more  room,  and  would  not  be  exposed  to  the  dust  produced 
by  his  fellow  workman.  Each  workman  should  exercise  more 
care  in  the  management  of  the  dust  which  he  produces.  Instead 
of  sweeping  the  dust  from  the  stone  on  which  he  is  working  and 
scattering  it  into  the  air  again,  he  should  gather  it  up  carefully 


GORDON.  199 

with  a  brush  and  deposit  it  in  a  receptacle  for  the  purpose.  The 
sheds  should  be  provided  with  windows  sufficient  to  give  abundance 
of  light,  so  that  it  would  not  be  necessary  for  the  workman  to  bend 
so  closely  over  the  stone  in  order  to  follow  his  marks  and  lines. 
Proper  appliances  should  be  used  to  place  the  stones  at  a  suitable 
height,  so  that  the  cutter  could  work  in  an  upright  position,  and 
he  should  be  taught  to  appreciate  the  importance  of  working  in 
this  position.  He  should  understand  the  importance  of  protecting 
himself,  when  perspiring,  from  exposure  to  the  cold  air,  while  the 
position  of  his  stone  is  being  changed.  He  should  be  made  to 
understand  his  susceptibility  to  tuberculosis,  and  the  danger  he 
incurs  from  sleeping  and  living  with  others  who  are  suffering  from 
the  disease.  He  should  change  his  occupation  when  the  symptoms 
of  chalicosis  or  dust  poisoning  begin  to  show  themselves,  before 
the  destructive  processes  in  the  lungs  have  become  advanced. 

Respirators  made  of  wire  netting  and  containing  a  suitable 
sponge  to  cover  the  mouth  and  nose  have  been  recommended, 
and  used  in  some  cases,  but  they  are  unsightly  and  inconvenient. 
The  sponge  soon  becomes  moistened  by  the  breath  and  clogged 
with  dust,  thus  requiring  frequent  washing  and  cleaning.  It 
further  interferes  with  speaking. 

It  seems  possible  that  a  contrivance  for  aspirating  the  dust 
might  be  made  similar  to  those  employed  in  shoe  factories,  wood- 
turning  shops  and  other  dust-producing  works,  the  use  of  which  is 
obligatory  in  many  cases.  This  would  involve  considerable  ex- 
pense, especially  for  the  smaller  sheds,  and  might  make  the  work 
of  granite  cutting  unprofitable.  But  if  the  several  smaller  man- 
ufacturers would  combine  and  build  more  commodious  and  more 
suitably  constructed  sheds  and  equip  them  with  contrivances  for 
handling  and  placing  the  stone  for  convenience  in  working,  and 
install  in  them  large  aspirating  pipes  with  adjustable  funnels  that 
could  be  brought  in  front  of  each  cutter,  into  which  the  dust 


200  TUBERCULOSIS  IN   MASSACHUSETTS. 

would  be  drawn  as  soon  as  made  and  carried  out  of  harm's  way, 
this  would  be  made  possible.  It  does  not  seem  that  the  expense 
would  be  very  excessive,  as  in  all  the  large  manufactories  they  al- 
ready have  powerful  machinery  for  the  production  of  compressed 
air  for  operating  the  pneumatic  appliances  and  surfacing  ma- 
chines, and  the  dust  itself  might  even  be  used  as  a  by-product  for 
various  useful  purposes. 


f 


I 


APPENDIX. 


t 


i 


List  of  articles  on  Tuberculosis  by 
Massachusetts  authors.' 


Abbott,  J.     Case  of  Abscess  of  the  Lung,  with  Enlarged  and  Tuberculous  Liver. 

Bost.  M.&S.  J.,  1842,  XXVL  77. 
Abbott,  S.  W.     Consumption:    an    Indoor   Disease.     Bost.   M.  &  S.  J.,    1898, 

CXXXVIH,  I. 

The  Decrease  of  Consumption  in  New  England.     Quart.  Pub.  Am.  Statist. 

Ass.,  1904,  IX,  I. 
Adams,  J.  D.     A  Report  of  Seventeen  Cases  in  Open-air  Treatment  for  Surgical 

Tuberculosis  in  Children.     Bost.  M.  &  S.  J.,  1906,  CLIV,  71. 
Adams,  J.   F.  A.     The  Segregation  of  Consumptives.     Med.  Com.   Mass.   Med. 

Soc,  1907,  XX,  397. 
Austin,  A.  E.     Some  Observations  on  Tubercular  Meningitis.     Bost.  M.  &  S.  J., 

1894,  CX XX I,  637. 
Ayer,  J.   B.     Cerebral  Symptoms  Connected  with  Phthisis.     Bost.  M.  &  S.  J., 

1889,  CXXI,  129. 
Bartlet,  E.     Fatal  Pleurisy  in  Tuberculosis  Patients  and  Chronic  Tubercular 

Peritonitis,  etc.    Am.  J.  M.  Sc,  1836,  XVIII,  325. 
Bates,  E.  A.     A  Case  of  Tuberculous  Pericarditis  with  Enormous  Effusion:   Gen- 
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BoARDMAN,  W.  S.    The  Treatment  of  PulmonaryTuberculosis  by  the  Subcutaneous 

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Bost.  M.  &  S.  J.,  1894,  CXXX,  492. 
Borland,  J.  N.     Cases  of  Tuberculosis.     Bost.  M.  &  S.  J.,  1868,  II,  145. 
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E.  P.  Dutton  &  Co. 

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Method  for  the  Radical  Arrest  of  Tuberculosis  of  the  Lungs  by  Artificial 

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Consumption  and  its  Treatment  in  all  its  Forms.     Boston,  1873,  G.  Lee  & 

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Method  for  Treating  Tubercular  Consumption.     Pamphlet,   20  pp..  New 

York,  1877,  Cherundy  &  Kienlo. 


1  References  to  surgical  tuberculosis,  with  a  few  exceptions,  arc  not  included. 


204  TUBERCULOSIS   IN   MASSACHUSETTS. 

BowDiTCH,    H.    I.     Pathological    Researches  on   Phthisis.     Revision   of  Cowan's 
Translation  of  Louis  on  Phthisis,  Boston,  1836. 

Paracentesis  Thoracis.     Am.  J.  M.  Sc,  1852,  XXIII,  103. 

Am.  M.  Month.,  1854,  I,  7. 

Cases  of  Anomalous   Development  of  Tubercles.     Am.   M.   Month.,  1855, 

IV,  I. 

Thoracentesis.     Host.  M.  &  S.  J.,  1857,  LVl,  349. 

Topographical  Distribution  and  Local  Origin  of  Consumption  in  Massachu- 

setts.    Med.  Com.  Mass.  Med.  Soc,  1862,  59. 

Paracentesis  Thoracis,  a  Resume  of  Twelve  Years'  Experience.     Am.  J.  M. 

Sc,  1863,  XLV,  17. 

Is  Consumption  ever  Contagious  or  Communicated  by  One  Person  to  Another 

in  any  Manner?     Host.  M.  &  S.  J.,  1864,  LXX,  329. 

Consumption    in    America.      Atlantic    Monthly,    Jan.,    Feb.,    and     Mar., 

1869. 

Thoracentesis  and  its  General  Results.     N.  Y.  Acad.  Med.,  Apr.  7,  1870. 

Thoracentesis.     Lond.  Practitioner,  Apr.,  1873. 

The  Isles  of  Shoals  as  a  Summer  Resort  for  the  Invalid  and  as  Presenting  a 

Specimen  of  One  of  the  Three  Climates  of  New  England.     Bost.  M.  &  S. 
J.,  i88i,CIV,  I. 

A  Case  of  Arrested  Phthisis.     Bost.  M.  &  S.  J.,  1883,  CIX,  569. 

Open-air  Travel  as  a  Cure  for  Consumption.     Trans.  Am.  Clim.  Ass.,  1889, 

VI,  194. 
BowDiTCH,  V.  Y.     The  Treatment  of  Pulmonary  Diseases  by  means  of  "  Pneu- 
matic Differentiation."     Bost.  M.  &  S.  J.,  1885,  CXIII,  55. 

A  Case  of  Phthisis  with  Numerous  Bacilli.     Complete  Arrest  of  the  Disease. 

Bost.  M.  &S.  J.,  1885,  CXIII,  558. 

Ten    Months'  Experience    with    Pneumatic    Differentiation.     Trans.    Am. 

Clim.  Ass.,  1886,  III,  47. 

Comparative  Importance  of  Different  Climatic  Attributes  in  the  Treatment 

of  Pulmonary  Consumption.     Trans.  Am.  Clim.  Ass.,  1888,  V,  44. 

Two  Cases  of  Phthisis  Treated  by  Intrapulmonary  Infections.     Bost.  M.  & 

S.  J.,  1889,  CXX,  455. 

Comparative  Results  in  Ninety  Cases  of  Pleurisy  with  special  reference  to 

the  Development  of  Phthisis  Pulmonalis.     Trans.  Am.  Clim.  Ass.,  1889, 
VI,  I. 

The  Establishment  of  Sanitaria  for  Pulmonary  Diseases  in  the  Vicinity  of 

our  Great  Cities.     Bost.  M.  &  S.  J.,  1892,  CXXVI,  191. 

Three  Years'  Experience  with  Sanitarium  Treatment  of  Pulmonary  Diseases 

near  Boston.     Trans.  Am.  Clim.  Ass.,  1894,  X,  254. 

A  Plea   for   Moderation    in    our   Statement    Regarding    the    Contagious- 

ness of  Pulmonary  Consumption.     Bost.  M.  &  S.  J.,   1896,  CXXXIV, 
637. 


APPENDIX.  205 

BowDiTCH,  V.  Y.  The  Treatment  of  Phthisis  in  Sanitaria  near  our  Homes.  Bost. 
M.  &S.  J.,  1896,  CXXXV,  125. 

Suggestions:  the  Result  of  Recent   Experiences  with  Phthisical  Patients. 

Trans.  Am.  Clim.  Ass.,  1898,  XIV,  28. 

State  Sanatoria  for  Tuberculosis.     Providence  M.  J.,  1900-01,  I,  5. 

The  Massachusetts  State  Hospital  for  Consumptives  at  Rutland;    its  Pur- 

poses and  the  Work  Accomplished  during  the  First  Year.     Bost.  M.  &  S. 
J.,  1900,  CLXII,  127. 

The  Home  (Sanitarium)  Treatment  Versus  the  Climatic  Treatment  of  Con- 

sumption.    Bost.  M.  &  S.  J.,  1901,  CLXV,  328. 

The  Care  of  Consumptives  in  State  and  Private  Sanatoria  in  Massachusetts. 

Maryland  M.  J.,  1902,  XLV,  97. 

Subsequent  Histories  of  Seventy-nine  Arrested  Cases  Treated  at  the  Sharon 

Sanitarium,  1891-1902.     Trans.  Am.  Clim.  Ass.,  1903,  XIX,  64. 

Origin  and  Growth  of  Sanatoria  for  Tuberculosis  in  Massachusetts.    J.  of 

Tuberculosis,  Nashville,  1903,  V,  147. 

■ Arrested  Tuberculosis,  Subsequent  Histories  of  Cases  Treated  at  the  Sharon 

Sanatorium.     Bost.  M.  &  S.  J.,  1904,  CL,  309. 

Pulmonary  Tuberculosis  and  Sanatorium  Treatment.     Bost.  M.  &  S.  J., 

1904,  CLI,  589. 

and  Dunham,  H.  B.     Six  Years'  Experience  at  the  Massachusetts  State 

Sanatorium  for  Tuberculosis.     J.  Am.  M.  Ass.,  1905,  XLIV,  1973. 

The  Treatment  of  Phthisis  in  Sanatoria  near  our  Homes.     Med.  Com.  Mass. 

Med.  Soc.,  1906,  XVII,  10 1. 

The  Scope  and  Aim  of  State  Sanatoria  for  Tuberculosis.     Trans,  of  the 

Nat'l  Ass.  for  the  Study  and  Prevention  of  Tuberculosis,  1906,  II,  287. 

and  Griffin,  W.  A.     Subsequent   Histories  of  One  Hundred  and  Sixty 

"Arrested  Cases"  of  Pulmonary  Tuberculosis  Treated  at  the  Sharon  San- 
atorium, 1891-1906.    J.  Am.  M.  Ass.,  1907,  XLVIII,  2016. 

The  English  Sanatorium.     Jour,  of  the  Outdoor  Life.     1907,111,461. 

Bowen,  J.  T.    The  Question  of  a  Mixed  Infection  from  Syphilis  and  Tuberculosis. 

Bost.  M.  &  S.  J.,  1891,  CXXV,  467. 

The  Pathology  of  Cutaneous  Tuberculosis.     Bost.  M.  &S.  J.,  1891,  125,  516. 

Bradford,  E.  H.  Open-air  Treatment  of  Bone  Tuberculosis  at  the  Wellesley  Con- 
valescent Home;  with  a  list  of  Thirty  Permanently  Cured  Cases.  Bost. 
M.  &S.  J.,  1906,  CXLIV,  57. 

Brackett,    E.   G.     The  Conservative   Treatment   of  Tubercular  Joint-Disease. 

Bost.  M.  &  S.  J.,  1898,  CXXXVIII,  83. 
Brown,  P.     Pulmonary  Tuberculosis  and  the  Roentgen  Rays.     Bost.  M.  &  S.  J., 

1907,  CLVII,  417. 
BucHAN,  W.  T.     A  Manual  of  Self-Management  and  Cure  in  all  Cases  of  Pulmonary 

Consumption  and  all  Diseases  of  the  Chest  and  Lungs.     Pamphlet,  48  pp., 

Boston,  1846,  D.  F.  Bradlee. 


206  TUBERCULOSIS   IN   MASSACHUSETTS. 

BuRRAGE,  W.  L.  A  Case  of  Primary  Tuberculosis  of  the  Female  Bladder  Diag- 
nosed and  Treated  by  Howard  Kelly's  New  Method  of  Direct  Inspection 
with  Large  Endoscopes.     Bost.  M.  &  S.  J.,  1894,  CXXXl,  77. 

Burnett,  W.  J.  Considerations  on  a  Change  of  Climate  by  Northern  Invalids, 
and  the  Climate  of  Aiken,  South  Carolina.  Bost.  M.  &  S.  J.,  1851,  XLV, 
269. 

A  Consideration  of  some  of  the  Relations  of  Climate  to  Tubercular  Disease. 

Bost.  M.  &  S.  J.,  1852,  XLV,  449. 
BuRRELL,  H.  L.     Surgical  Tuberculosis.     Bost.  M.  &  S.  J.,  1903,  CXLVII,  685,  and 

CXLIX,  I. 
,    CusHiNG,  H.  W.,  and  Stone,  J.  S.     Tuberculous  Ulceration  of  the  Lower 

Ileum.     Perforation.     Peritonitis.     Operation.     Death    at    the    End    of 

Five  Weeks.     Bost.  M.  &  S.  J..  1904,  CLI,  685. 
Cabot,  A.  T.     Remarks  upon  the  Proper  Surgical  Treatment  of  Tuberculous  Bone 

Disease.     Bost.  M.  &  S.  J.,  1898,  CXXXVIII,  79. 

The  Physician's  Duty  towards  Tuberculosis.     Bost.  M.  &  S.  J.,  1905,  CLIII, 

657. 
Call,  E.  L.     Acute  Tuberculosis  in  Puerperal  Women.     Bost.  M.  &  S.  J.,  1897, 

CXXXVII,  343. 
Channing,  W.     Softening  of  the  Brain,  with  General  Tuberculosis.     Bost.  M.  &  S. 

J.,  1863,  LXIX,  9. 

Tuberculosis  in  Mental  Disease.     Bost.  M.  &  S.  J.,  1894,  CXXXI,  63. 

The  Importance  of  Frequent  Observations  of  Temperature  in  the  Diagnosis 

of  Chronic  Tuberculosis.     Bost.  M.  &  S.  J.,  1895,  CXXXI II,  609. 
Cheney,  F.  E.     A  Case  of  Tuberculosis  of  the  Conjunctiva,  Probably  Primary, 

Followed  by  General  Infection  and  Death.     Bost.  M.  &  S.  J.,   1896, 

CXXXV,  490. 
Chute,  A.  L.     Urethral  Tuberculosis,  with  Report  of  a  Case.     Bost.  M.  &  S.  J., 

1903,  CXLIX,  361. 
Clapp,  H.  C.     Is  Consumption  Contagious  and  can  it  be  transmitted  by  Means  of 

Food?     Boston,  1880,  178  pp.,  Otis  Clapp  &  Son. 

Phthisis  Pulmonalis.     Amdt's  System  of  Medicine,  Vol.  I.,  Phila.,  1885-6, 

F.  E.  Boericke. 

Tuberculosis.    Arndt's  System  of  Medicine,  Vol.  Ill,  Phila.,  1885-6,  F.  E. 

Boericke. 

The  Dangers  of  the  Microscope  in  the  Early  Diagnosis  of  Pulmonary  Tuber- 

culosis.    Am.  Med.,  1904,  VIII,  1010. 

What  Cases  are  suitable  for  Admission  to  a  State  Sanatorium  for  Tubercu- 

losis, especially  in  New  England?     Am.  Med.,  1905,  X,  148. 

and  Lapham,  G.  N.     Basic  Pulmonary  Tuberculosis.     N.  E.  Med.  Gazette, 

1905.  XL,  343. 

On  the  Importance  of  Early  Diagnosis  in  Cases  of  Pulmonary  Tuberculosis. 

Bost.  M.  &  S.  J.,  1906,  CLIV,  65. 


APPENDIX. 


207 


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Cold  Air  in  Incurable  Consumption.     Bost.  M.  &  S.  J.,  1907,  CLVI,  850. 

Pulmonary  Tuberculosis:  Some  of  the  Details  of  its  Modern  Hygienic  Treat- 

ment which  can  be  applied  in  treating  the  Patient  at  his  own  Home.     N. 
Y.  Med.  Record,  1907,  LXXI,  718. 

Diet  in  Pulmonary  Tuberculosis.     N.  Y.  Med.  Record,  1907,  LXXI,  1074. 

Clark,  J.  P.     Tubercular  Tumors  of  the  Larynx.      Am.  J.  M.  Sc,    1895,  CIX, 

525- 

The  Condition  of  the  Nose  in  Phthisical  Patients.     Bost.  M.  &  S.  J.,  1895. 

CXXXIII,  343. 

Clarke,  A.  B.  Case  of  Co-existence  of  Cancer  and  Tubercle.  Bost.  M.  &  S.  J., 
1863.  LXVn,474. 

Clarke,  A.  P.     Pelvic  Tuberculosis.     Bost.  M.  &  S.  J.,  1899,  CXLI,  87. 

Clarke,  E.  H.  Phthisis  and  Pleurisy  with  Pneumohydrothorax,  treated  by  Para- 
centesis Thoracis;  Iodine  Injections  into  the  Pleural  Cavity.  Bost.  M. 
&S.  J.,  1859,  LXI,  249. 

Hydrate  of  Chloral,  with  Cases  illustrating  its  Action.  —  Phthisis.     Bost. 

M.  &  S.  J.,  1870,  LXXXII.  455  and  456. 

Cobb,  F.  Pseudo-tuberculosis  of  the  Peritoneum.  Report  of  a  Case.  Bost.  M. 
&S.  J.,  1907,  CLVI  I,  861. 

Coffin,  A.  On  Climate  in  the  Treatment  of  Pulmonary  Tuberculosis,  etc.,  with 
.  special  Reference  to  that  of  Aiken,  South  Carolina.  Bost.  M.  &  S.  J.,  1868, 
II,  321. 

CooTE,  C.  T.  A  Case  of  Cancer  of  the  Stomach  associated  with  Tubercular  Disease 
of  the  Lungs.     Bost.  M.  &  S.  J.,  i860,  LXI  I,  204. 

Copp,  O.  What  should  be  the  State  Policy  regarding  Tuberculosis  in  Insane  Asy- 
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Cornell,  W.  M.  Consumption  Forestalled  and  Prevented.  Boston,  1846,  120  pp., 
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Crosby  &  H.  P.  Nichols. 

Inhalation  and  other  Treatment  in  Phthisis.     Bost.  M.  &  S.  J.,  1854,  L,  392. 

CoTTiNG,  B.  E.     Statistics  of  Consumption  in  Roxbury.     Bost.  M.  &  S.  J.,  1854, 

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Probable  Acute  Tuberculosis,  Terror  apparently  the  Immediate  Cause  of 

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>7- 
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208  TUBERCULOSIS   IN    MASSACHUSETTS. 

Gushing,  E.  W.  The  Specific  and  Infectious  Character  of  Tuberculosis,  with  Ex- 
hibition of  the  Bacilli  of  Tuberculosis  and  those  of  Malignant  Pustule 
(Anthrax).     Bost.  M.  &  S.  J.,  1885,  CXIII,  553. 

The  Staining  of  the  Bacillus  of  Tubercle.     Bost.  M.  &  S.  J.,  1886,  CXIV. 

268. 
Gushing,  H.  W.     Supposed  Tuberculous  Tumor  of  the  Pons  Cerebri.     Bost.  M.  & 

S.  J.,  1904,  CLI,  266. 
Cutler,   E.  G.     Record  of  Two  Cases  of    Beginning   Pulmonary  Tuberculosis 
•  Treated  with  Subcutaneous  Injections  of  Koch's  Tuberculin  T.  R.     Bost. 

M.  &S.  J.,  1897,  GXXXVII,  571. 
DeBlois,  T.  a.     The  Rapid  Fatality  of  Tuberculosis  when  involving  the  Pharynx. 

Bost.  M.  &  S.  J.,  1885,  CXIII,  397. 

Sub-glottic  Tubercular  Lesions  of  the  Larynx.     Bost.  M.  &  S.  J.,  1904,  CLI, 

321. 

DiLLENBACH,  H.  P.  Medicated  Inhalation  in  the  Treatment  of  Pulmonary  Con- 
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Boston,  1857,  214  pp.,  G.  C.  Rand. 

Donaldson,  F.  The  Influence  of  City  Life  and  Occupations  in  developing  Pulmo- 
nary Consumption.     Pamphlet,  20  pp.,  Cambridge,  1876,  Riverside  Press. 

Dunham,  H.  B.  Contractile  Processes  in  the  Lungs  as  a  Result  of  Phthisis  with 
Reference  especially  to  their  Production  of  Permanent  Dextrocardia. 
Bost.  M.  &  S.  J.,  1905,  CLI  V,  1 55. 

Some  Observations  on  Tuberculin.     Am.  Med.,  1901. 

Pulmonary  Gymnastics  in  Tuberculosis.     Bost.  M.  &  S.  J.,  1906,  CLV,  61. 

Favorable  and  Unfavorable  Climates  for  Tuberculosis.     Colorado  M.  J., 

March,  1904. 
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Bost.  M.  &  S.  J.,  1907,  CLVII,  389. 
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Bost.  M.  &  S.  J.,  1843,  XXVI 1 1,  409  and  449. 
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1872,  X,  326. 
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1896,  XVII,  91. 
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Ellis,  G.     Tubercle —  Its  Pathology  and  especially  its  Relation  to  Inflammation. 

Am.  J.  M.  Sc,  i860,  XXXIX,  203. 

Recent  Views  of  Tubercle.     Bost.  M.  &  S.  J.,  1870,  V,  166. 

Ernst,  H.  G.  A  Contribution  to  the  Study  of  the  Tubercle  Bacillus.  Bost.  M.  & 
S.  J.,  1883,  CIX,  100,  and  121. 

Some  Observations  on  the  Bacillus  of  Tuberculosis.     Am.  J.  M.  Sc,  1884, 

LXXXVIII,  367. 


APPENDIX. 


209 


Ernst,  H.  C.  How  far  may  a  Cow  be  Tuberculous  before  her  Milk  becomes 
Dangerous  as  an  Article  of  Food?  Congr^s  pour  I'Etude  de  la  Tuber- 
culose,  Paris,   1890.    Am.  J.  M.  Sc,  1889,  XCVill,  439. 

Koch's  Treatment  of  Tuberculosis.     Bost.  M.  &  S.  J.,  1891,  CXXIV,  23,  77, 

and  105. 

Preliminary  Report  on  the  Clinical  Use  of  Tuberculin.     Bost.  M.  &  S.  J., 

1891,  CXXV,  5,  25,  55,  76,  and  131. 

Tuberculin  and  Tuberculosis.     Trans,  of  Ass.  of  Am.  Phys.,  1891,  VI,  15. 

Carosso's  Treatment  of  Pulmonary  Tuberculosis.     Trans,  of  Ass.  of  Am. 

Phys.,  1895,  X,  237. 

Infectiousness  of  Milk  (Tuberculous).     (Result  of  Investigations  made  for 

the  Trustees  of  the  Massachusetts  Society  for  Promoting  Agriculture.) 
Boston,  1895.     Mass.  Soc.  for  Promoting  Agriculture. 

and  Smith,  T.     Report  on  Cattle  treated  with  Tuberculin.     Mass.  House  of 

Representatives,  No.  1341,  1897. 
FiTz,  R.  H.     The  Theory  of  Tuberculosis.     Med.  Com.  Mass.  Med.  Soc,  1871,  X, 
30. 

Tuberculosis  of  the  Genito-urinary  Organs  and  Caries  of  the  Vertebra. 

Bost.  M.  &  S.  J.,  1877,  XCVI,  79. 
Floyd,  C,  and  Hawes,  J.  B.,  2d.     The  Ophthalmo-tuberculin  Reaction;    Some 

Observations.     J.  M.  Research,  1908,  XVII,  495. 
Floyd,  C,  aTid  Worthington,  A.  M.     The  Value  of  Vaccine  Therapy  to  the  Gen- 
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1908,  CLVIII,  5. 
French,  J.  M.     Consumption  in  Massachusetts.     Bost  M.  &  S.  J.,  1890,  CXXIII, 

340. 
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1896,  CXXXIV,  173. 
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The  Treatment   of   Tuberculosis   of   the    Hip-Joint    (Hip    Disease).     Bost. 

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210  TUBERCULOSIS    IN   MASSACHUSETTS. 

Griffin,  W.  A.  Weather  Conditions  at  the  Sharon  Sanatorium.  Bost.  M.  Sc  S. 
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The  Open-air  Treatment  of  Tuberculosis.         Bost.  M.  &  S.  J.,  1906,  CLIV, 

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Tubercular  Meningitis  in  the  Adult.      N.   Eng.  Q.  J.  M.  &  S..    1842-3, 

I,    II. 

Tuberculous  Disease  of  the  Spinal  Marrow.     N.  Eng.  Q.  J.  M.  &  S.',  1842-3. 

I,4>9- 

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Is  Tuberculosis  of  the  Lungs  ever  Contagious?     Bost.  M.  &  S.  J.,   1887 

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On  the  Selection  of  a  Climate  for  Patients  with  Pulmonary  Tuberculosis 

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Indications  and  Contra-indications  for  Altitude  in  the  Treatment  of  Pul- 

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On  the  Return  of  Cured  Tuberculous  Patients  from  High  Altitudes.    The 

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Shall  Anything  be  done  by  Legal  Authority  to  prevent  the  Spread  of  Tuber- 

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Common  Errors  of  General  Practitioners  in  dealing  with  Pulmonary  Tuber- 

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Climate  in  Pulmonary  Tuberculosis.     Bost.  M.  &  S.  J.,  1901,  CXLIV,  53. 


212  TUBERCULOSIS   IN  MASSACHUSETTS. 

Knight,  F.  I.     The  Association  of  Tuberculosis  and  Syphilis.     Trans.  Am.  Clim. 
Ass.,  1901,  XVII,  142. 

What  shall  we  do  with  Patients  having  Pulmonary  Tuberculosis?     Bost. 

M.  &S.  J.,  1904,  CLI.  257. 

Discussion  of  the  Report  on  Early  Diagnosis  of  Tuberculosis.     Bost.  M.  & 

S.  J.,  1905,  CLII,  665. 

Climate  as  a  Factor  in  the  Treatment  of  Tuberculosis.     Trans.  Nat'l  Ass. 

for  the  Study  and  Prevention  of  Tuberculosis,  1906,  II,  437. 

The  Importance  of  Supervision  of  Patients  after  leaving  Sanatoria  Appar- 

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CXXXI,  59. 
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the  Study  and  Prevention  of  Tuberculosis,  1908. 
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Infections  of  the  Respiratory  Tract  with  Influenza  Bacilli  and  Other  Organ- 

isms,  their  Clinical   and    Pathological   Similarity,   and   Confusion   with 

Tuberculosis.     Bost.  M.  &  S.  J.,  1905,  CLII,  537  and  574. 
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APPENDIX.  213 

Miller,  L.  C.     The  Decrease  in  the  Death-rate  of  Consumption.     Bost.  M.  &  S.  J., 

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Bost.  M.  &  S.  J.,  1872,  X,67. 
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45  pp.,  Boston,  R.  Hodge. 
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by  Laparotomy.     Bost.  M.  &  S.  J.,  1888,  CXIX,  535. 
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Tuberculosis  of  the   Kidney  in  an  Infant.     N.  Y.  M.  J.,   1906,  LXXXIV, 

108 1. 

Management  and  Treatment  of  Tuberculosis  in  Infants  and  Children.     N.  Y. 

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Munro,  J.  C.     Report  of  Twenty-four  Cases  of  Acute  Miliary  Tuberculosis.     Bost. 
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The  Influence  of  Climate  on  Genito-urinary  Tuberculosis.     Bost.  M.  &  S. 

J.,  1896,  CXXXV,  221. 
Nichols,  J.    H.     What   Special   Instructions   regarding  Tuberculosis  should  be 

given  Institution  Nurses  and  other  Employees?     Are  Nurses  caring  for 

Cases  of  Tuberculosis  in  Danger  of  contracting  the  Disease?     Bost.  M. 

&S.J.,  1906,  CLIV,  65. 
Osgood,  F.  H.     Tuberculosis  in  Cattle.     Bost.  M.  &  S.  J.,  1894,  CXXXI,  55. 

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Otis,  E.  O.     The  Treatment   of   Phthisis  by    Inhalation  of  Antiseptic  through 

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Pulmonary  Tuberculosis  with  Special  Reference  to  its  Prophylaxis,   Hy- 

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and  365. 

Climatic  Therapeutics  in  the  Treatment  of  Pulmonary  Tuberculosis.     Bost. 

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Some  Methods  of  Chest  Examination,  Supplementary  to  Auscultation  and 

Percussion.     Bost.  M.  &  S.  J.,  1895,  CXXXII,  355. 

Treatment  of  Advanced  (Hopeless)  Cases  of  Phthisis.     Bost.  M.  &  S.  J., 

1895,  CXXXII,  609. 

The  Value  of  Respiratory  Gymnastics  in  maintaining  the  Integrity  of  the 

Lungs  as  an  Aid  in  the  Treatment  of  Diseases  of  these  Organs.     Bost. 
M.  &S.  J.,  1896,  CXXXIV,  525. 

The  Sanatorium  or  Closed  Treatment  of  Phthisis.     Bost.  M.  &  S.  J.,  1896, 

CXXXV,  241. 


214  TUBERCULOSIS    IN    MASSACHUSETTS. 

Otis,  E.  O.     Are   Especial  Hospitals   or   Homes  for  Consumptives  a  Source  of 
Danger  to  their  Neighborhood?     Bost.  M.  &  S.  J.,  1897,  CXXXVI,  305. 

The  Causes  and  Conditions  of  Pulmonary  Tuberculosis,  and  how  to  avoid 

them.     Am.  J.  M.  Sc,  1898,  CXVI,  532. 

Hospitals  and  Sanatoria  for  Consumption  Abroad.     Bost.  M.  &  S.  J.,  1898 

CXXXVIII,265,  313  and  329. 

Some  Modern  Methods  of  the  Treatment  of  Phthisis  and  its  Symptoms 

Bost.  M.  &  S.  J.,  1898,  CXXXIX,  31  and  55. 

The  Value  of  the  Tuberculin  Test  in  the  Diagnosis  of  Tuberculosis.     Bost 

M.  &S.  J.,  1899,  CXLI,  21. 

Some  Notes  upon  the  Tuberculin  Test.     Bost.  M.  &  S.  J.,  1899,  CXLI,  247 

The  Struggle  against  Tuberculosis.     Bost.  M.  &  S.  J.,  1899,  CXLI,  280. 

Especial    Hospitals  for  Consumptives   Among  the   Poor  in    Large  Cities 

Phila.  M.J..  1900,  V,  1468. 

The  Duty  of  the  State  and  Municipality  in  the  Care  of  Pulmonary  Tuber- 

culosis among  the  Poor.     Albany  M.  Ann.,  1900,  XXI,  198. 

Further  Notes  upon  the  Diagnostic  Test  of  Tuberculin.     Med.  News,  N. 

Y.,  1901,  LXXIX,  281. 

State  Sanatoria  for  Tuberculosis.     Providence  M.  J.,  1901,  I  and  11,  8. 

Measures  for  stamping  out  Consumption.     Proc.  Am.   Invalid   Aid    Soc,  § 

1 90 1. 

The   Home  Treatment   of  Tuberculosis   versus   the  Climatic  Treatment. 

Bost.  M.  &  S.  J.,  1901,  CXLIV,  609. 

The  City  Consumptive   Hospital  and   the  Duty  of  the  Municipality  and 

People    Regarding   Consumption.      Bost.    M.    &    S.    J.,    1902,    CXLVI, 
461. 

The  Struggle  Against  Consumption.     Bost.  M.  &  S.  J.,  1902,  CXLVI,  625. 

Dispensaries  for  Tuberculosis  with  a  Description  of  the  Tuberculosis  De- 

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The  Significance  of  the  Tuberculosis  Crusade  and  its  Future.     Bost.  M.  &  ' 

S.  J.,  1904,  CL,  694.  ; 

Dispensaries  for  Tuberculosis.     Charities,  1904.  ^ 

The  Tuberculosis  Problem  and  some  Suggestions  in  dealing  with  it.     Bost.  k 

M.  &S.  J.,  1905,  CLII.  127.  f 

Home  Treatment  of  Tuberculosis  either  in  favorable  or  unfavorable  Climate.  |- 

Trans.  Nat'l  Ass.  for  the  Study  and  Prevention  of  Tuberculosis,   1905,  ; 

1.389- 

The  Municipal  Control  of  Tuberculosis.     Bost.  M.  &  S.  J..  1905,  CLII  I,  716. 

Workshops  and  Tuberculosis.     Bull.  No.  5  of  the  Civic  Federation  of  N. 

Eng.,  May,  1906. 

The  Use  and   Abuse  of   Pulmonary  Gymnastics   in   Tuberculosis.     Bost. 

M.&S.  J..  1906.  CLV.  59. 


APPENDIX. 


215 


Otis,  E.  O.     The  Tuberculosis  Dispensary;  Its  Methods,  Value  and  Limitations. 
J.Am.  M.  Ass.,  1906,  XLVII,2i54. 

The  Blood  Pressure  as  a  Guide  in  the  Treatment  of  Tuberculosis.     Bost. 

M.  &S.  J.,  1907,  CLVII,  211. 

Public  Provision  for  Advanced  Cases  of  Tuberculosis.    J.  Am.  jM.  Ass., 

1907,  XLIX,  818. 

The   Early   Diagnosis  of  Pulmonary  Tuberculosis  for  the  General   Prac- 

titioner.    Bost.  M.  &  S.J. ,  1907,  CLVII,  361. 
Palmer,  S.  E.     A  Case  of  Tuberculosis  Contagion.     Bost.  M.  &  S.  J.,  1904,  CL, 

588. 
Parker,  W.  T.     Should  the  State  treat  Tuberculosis?     Bost.  M.  &  S.  J.,  1896, 

CXXXIV,  427. 
Peters,  A.     Prevalence  of  Bovine  Tuberculosis.     Bost.  M.  &  S.  J.,  1894,  CXXXI, 

525- 

The  Suppression  of  Tuberculosis  in  our  Dairy  Herds.     Bost.  M.  &  S.  J., 

1906,  CLIV,  67. 
Pratt,  J.  H.     The  "Home  Sanatorium"  Treatment  of  Consumption.     Bost.  M. 
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The  Organization  of  Tuberculosis  Classes.     Bost.  M.  &  S.  J.,  1907,  CLVII, 

285. 
Prescott,  W.  H.,  and  Goldthwait,  J.  E.     Observations  on  Tuberculosis  of  the 

Kidney,  with  a  Report  of  Cases.     Bost.  M.  &  S.  J..  1891,  CXXIV,  61. 
Rand,  I.     Observations  on  Phthisis  Pulmonalis  and  the  Use  of  Digitalis  Purpurea 

in   the  Treatment  of  that   Disease.     Pamphlet,   26  pp.,  Boston,  1804, 

the  Repertory  Office. 
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145. 
Richardson,  O.     Autopsy  in  Dr.  Townsend's  Case  of  Tuberculosis  in  an  Infant. 

Bost.  M.  &S.  J.,  1905,  CLIII,  18. 
Rogers,  A.  E.     The  Successful  Treatment  of  Tuberculosis.     Bost.  M.  &  S.  J., 

1906,  CLIV,  291. 
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Bost.  M.  &  S.  J.,  1906,  CLIV,  62. 
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61. 
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XVI,  75. 


2l6  TUBERCULOSIS    IN    MASSACHUSETTS. 

Sears,  G.  G.     Four  Cases  of  Phthisis  treated  by  Inhalations  of  Hot  Air.     Bost. 
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Remarks  on  Two  Hundred  Cases  of  Phthisis.     Bost.  M.  &  S.  J.,    1895, 

CXXXII,  323. 

The  Tuberculin  Test  in  Ten  Cases  of  Acute  Pleurisy.     Bost.  M.  &  S.  J., 

1897,  CXXXVl,  121. 
Sessions,  W.  R.    The  Agricultural  Aspect  of  Tuberculosis.     Bost.  M.  &  S.  J., 

1894,  CXXXI,  531. 
Shattuck,  F.  C.     Recent  Progress  in  the  Treatment  of  Thoracic  Diseases.    The 

Use  of   the   Hypophosphites   in    Phthisis.     Expectoration    in    Phthisis. 

Bost.  M.  &  S.  J.,  1877,  XCVI,  462. 

Pulmonary  Consumption.     Cycl.    Pract.    Med.   (Ziemmsen),  N.    Y.,    1881, 

Supplement,  318. 

Tuberculosis.    Cycl.  Pract.  Med.  (Ziemmsen),  N.  Y.,  1881,  Supplement,  334. 

The  Home  Treatment  of  Consumption.     Bost.  M.  &  S.  J.,  1885,  CXII,  576. 

Some    Hospital  Cases  of   Phthisis,   marked   Improvement  under  General 

Treatment,  with  special  Reference  to  Alimentation.     Bost.  M.  &  S.  J., 
1887,  CXVI,  580. 

Clinical  Notes  on  Bergeon's  Methods  of  treating  Phthisis.     Bost.  M.  &  S. 

J.,  1887,  CXVI,  612. 

Prognosis  and  Treatment  of  Tubercular  Peritonitis.     Am.  J.  M.  Sc,  1902, 

CXXIV,  I. 

The  Past,  Present  and  Future  of  Tuberculosis.     Bost.  M.  &  S.  J.,   1907, 

CLVII,  133. 
Shattuck,  G.  B.     Acute  Miliary  Tuberculosis.     Bost.  M.  &  S.  J.,  1886,  CXIV,  1 56. 

Pleurisy  with  Effusion,  Tuberculous  Peritonitis.     Addison's  Disease.     Bost. 

M.  &  S.  J.,  1905,  CLII,  551. 
Shl'Mway,  H.  L.     a  Hand-book  of  Tuberculosis  among  Cattle.     Boston,   1895, 

'77  PP'  Roberts  Bros. 
Smith,  T.     A  Comparative  Study  of  Bovine  Tubercle  Bacilli  and  of  Human  Bacilli 

from  Sputum.     J.  Exper.  M.,  1898,  III,  451. 

Notes  on  a  Tubercle  Bacillus  having  a  Low  Degree  of  Virulence.     J.  Bost. 

Soc.  M.  Sc,  1898,  HI,  33. 

Comparative  Studies  of  Bovine  Tubercle  Bacilli  and  of  Human  (Sputum). 

Bost.  M.  &  S.  J.,  1898,  CXXXVl II.  497. 

The  Thermal  Deathpoint  of  Tubercle  Bacilli  in  Milk  and  some  other  fluids. 

J.  Exper.  M.,  1899,  IV,  217. 

The    Relation    between    Bovine   and    Human   Tuberculosis.     Med.    News, 

N.  Y.,  LXXX,  343. 

Studies  in  Mammalian  Tubercle  Bacilli.     Bost.  M.  &  S.  J.,  1903,  CXLVIII, 

645. 

A  Study  of  the  Tubercle  Bacilli  Isolated  from  Three  Cases  of  Tuberculosis 

of  the  Mesenteric  Lymph  Nodes.  Trans.  Ass.  Am.  Phys.,  1904,  XIX,  373. 


APPENDIX.  217 

Smith,  T.  Studies  in  Mammalian  Tubercle  Bacilli.  111.  Description  of  a  Bovine 
Bacillus  from  the  Human  Body.  A  Culture  Test  for  Distinguishing 
the  Human  from  the  Bovine  Type  of  Bacilli.     J.  M.  Research,  1905,  XIII, 

253- 

The  Reaction  Curve  of  Tubercle  Bacilli  from  Different  Sources  in  Bouillon 

Containing    Different    Amounts    of   Glycerine.     J.    M.    Research,    1905, 
XIII.  405. 

What  is  the  Relation  between  Human  and  Bovine  Tuberculosis,  and  how 

does  it  affect  Inmates  of  Public  Institutions?     Bost.  M.  &  S.  J.,  1906^ 
CLIV,  60. 

The  Parasitism  of  the  Tubercle  Bacilli  and  its  Bearing  on  Infection  and 

Immunity.     J.  Am.  M.  Ass.,  1906,  XLVI,  1247  and  1345. 

Note  on  the  Stability  of  the  Cultural  Characters  of  Tubercle  Bacilli  with 

special  Reference  to  the  Production  of  Capsules.     Trans.  Nat'l  Ass.  for 
the  Study  and  Prevention  of  Tuberculosis,  1905,  I,  212. 

and  Brown,  H.  R.     Studies  in  Mammalian  Tubercle  Bacilli.     IV.     Bacilli 

Resembling  the  Bovine  Type  from  Four  Cases  in  Man.     J.  M.  Research, 
1907,  XVI,  435. 

The  Channels  of  Infection  in  Tuberculosis  together  with  some  Remarks  on 

the  Outlook  concerning  a  Specific  Therapy.     Med.  Com.  Mass.  Med.  Soc., 
1907,  449. 

The  Vaccination  of  Cattle  against  Tuberculosis.     J.  M.  Research,  1908, 

XVIII,  451. 
Smith,  W.  E.     A  Study  of  Phthisis  and  Pneumonia  in  Massachusetts;   Statistical 

and  Climatological.  Med.  Com.  Mass.  Med.  Soc,  1887,  XIV,  245. 
Stevens,  C.W.  Is  Phthisis  Contagious?  Bost.  M.  &  S.  J.,  1872,  IX,  168. 
Stone,  A.  K.     Clinical  Value  of  the  Bacillus  of  Tuberculosis.     Bost.  M.  &  S.  J., 

1890,  CXXIII,  515. 

Why  the  Sputa  of  Tuberculous  Patients  should  be  Destroyed.     Am.  J. 

M.  Sc,  1891,  CI,  275. 

Impressions  of  the  British  Congress  on  Tuberculosis.     Bost.  M.  &  S.  J., 

1901,  CXLV,  258. 

and  Wilson,   A.   M.     The  Geographical   Distribution  of  Tuberculosis  in 

Boston  in  1901-03  as  compared  with  the  Distribution  in  1885-90.     Bost. 
M.  &S.  J.,  1905,  CLII,  6. 

and  Floyd,  C.     The  Daily  Care  of  Consumptives  at  a  General  Hospital  as 

an  Aid  to  solving  Local  Tuberculosis  Problems.     Bost.  M.  &  S.  J.,  1907, 
CLVII,  141. 

A  Case  of  Intestinal  Tuberculosis,  with  Psychoneurotic  Symptoms.     Bost. 

M.  &S.  J.,  1907,  CLVII,  560. 
Strong,  L.  W.     Immunity  against  Tuberculosis.     Bost.  M.  &  S.  J.,  1906,  CLIV, 

140. 
Stuart,  F.  W.     Syphilis  or  Tuberculosis?     Bost.  M.  &  S.  J.,  1888,  CXIX,  574. 


2l8  TUBERCULOSIS    IN   MASSACHUSETTS. 

WEETSER,  W.     A  Treatise  on  Consumption;    embracing  an    Inquiry  into  the 
Influence  exerted  upon  it  by  Journeys,  Voyages,  and  Change  of  Climate. 
Boston,  1836,  254  pp.,  T.  H.  Carter. 
Thorndike,  p.     Genito-Urinary  Tuberculosis.     Bost.  M.  &  S.  J.,  1902,  CXLVI, 
607. 

and  Bailey,  W.  T.     Tuberculosis  of  the  Testicle.     Bost.  M.  &  S.  J.,  1902, 

CXLVIII,  13. 
Tileston,  W.     Passive  Hyperaemia  of  the  Lungs  and  Tuberculosis.    J.  Am.  M. 

Ass.,  1908,  L,  1 179. 
Tower,  C.  C.     A  Case  of  Tuberculosis  of  the  Pericardium  and  Bronchial  Lymph 

Glands.     Bost.  M.  &  S.  J.,  1889,  CXXl,  57. 
TowNSEND,  C.  W.    An  Unusual  Case  of  Tuberculosis  in  an  Infant.     Bost.  M.  & 

S.  J.,  1905,  CLIII,  17. 
Townsend,    D.     Results   obtained   at   the    Boston    Day-Camp   for   Tuberculous 

Patients.     Jour,  of  Outdoor  Life,  Dec,  1905. 

Day  Sanatorium  for  Consumptives,  Parker  Hill,  Boston.     Bost.  M.  &  S.  J., 

1906.  CLIV,  69. 

"Mattapan  Day-Camp."     Bost.  M.  &  S.  J.,  1908,  CLVIII,  246. 

McCarthy,   F.   P.,  a^id   Houghton,    R.     Mattapan    Day-Camp  for  Con- 

sumptives, Boston.     Bost.  M.  &  S.  J.,  1908,  CLVIII,  575. 
Verhoeff,   F.    H.    Tuberculous  Scleritis,   a  Commonly  Unrecognized   Form  of 

Tuberculosis.     Bost.  M.  &  S.  J.,  1907,  CLVI,  317. 
VicKERY,  H.  F.     Pulmonary  Tuberculosis  as  a  Sequel  to  Ordinary  Pleurisy  with 

Effusion.     Bost.  M.&  S.J. ,  1887,  CXVII,  521. 

The  Prevention  of  Tuberculosis.     Bost.  M.  &  S.  J.,  1894,  CXXX,  5. 

ViETOR,  A.  C.     A  Plan  for  the  Municipal  Control  of  Tuberculosis  in  Boston.     Bost. 

M.&S.  J.,  1902,  CXLVI,  131. 
Warren,  I.    Consumption  and  its  Treatment.     Bost.   M.  &  S.  J.,    1851,  XLV, 

449. 
Waterhouse,  H.     Phthisis  Pulmonalis.     N.  Eng.  M.  J.,  1823,  XII,  261. 
Watson,  F.  S.     A  Case  of  Tuberculosis  of  the  Bladder,  Prostate  and  Kidneys, 

Originating  in  Tuberculous  Epididymitis;  Autopsy.     Bost.  M.  &  S.  J., 

1888,  CXIX,  5. 

The  Surgical  Treatment  of  Renal  Tuberculosis.     Bost.  M.  &  S.  J.,  1907, 

CLVI,  263. 

Wheeler,  L.  Laparatomy  for  Tubercular  Peritonitis.  Med.  Com.  JMass.  Med. 
Soc,  1890,  XV,  231. 

White,  C.  J.  The  Modern  Conception  of  Tuberculosis  of  the  Skin.  Bost.  M.  & 
S.  J.,  1905,  CLIII,  291. 

White,  F.  W.  The  Diagnostic  Value  of  Tuberculin.  Bost.  M.  &  S.  J.,  1897. 
CXXXVII.  123. 

White,  J.  C.  Clinical  Aspects  and  Etiological  Relations  of  Cutaneous  Tubercu- 
losis.    Bost.  M.  &  S.  J..  1891.  CXXV,  509. 


APPENDIX. 


219 


Whitney,  W.  F.     The  Etiology  of  Tuberculosis.     Pamphlet,  16  pp.,  Cambridge, 

1882,  Riverside  Press. 
Whittier,  E.  N.     Persistent  High  Temperature  in  Tuberculosis  with  Tubercular 

Pharyngitis.     Bost.  M.  &  S.  J.,  1885,  CXIII,  513. 
Wilder,  C.  W.     Pulmonary  Consumption,  its  Causes,  Symptoms,  and  Treatment. 

Med.  Com.  Mass.  Med.  Soc,  1843,  ^'''  77- 
Wiley,  H.     Pulmonary  Consumption.     Bost.  M.  &  S.  J.,  1838,  XVIII,  85. 
WiLKiNs,  G.  C.     Tuberculosis  at  the  Long  island  Hospital.     Bost.  M.  &  S.  J., 

1902,  CXLVII,  579. 
Williams,  A.  H.     An  Unusual  Family  History  of  Tuberculosis.     Bost.  M.  &  S. 

J.,  1902,  CXLVI,  433. 
Williams,  F.  H.     Notes  on  X-rays  in  Medicine.     Trans.  Ass.  Am.  Phys.,  1896, 

XI,  375- 

A  Study  of  the  Adaptation  of  the  X-rays  to  Medical  Practice  and  some  of 

their  Uses.     Med.  &  Surg.  Reports  Bost.  City  Hosp.,  1897,  8  s.,  134. 

The  Roentgen  Rays  in  Thoracic  Diseases.     Am.  J.  M.  Sc,  1897,  CXIV,  665. 

Some  of  the  Medical  Uses  of  the  Roentgen  Rays.     Brit.  M.  J.,  1898,  I,  1006. 

X-ray  in  Medicine.     Med.  News,  1898,  LXXIl,  609. 

An  Outline  of  the  Clinical  Uses  of  the  Fluoroscope.     Med.  Com.  Mass.  Med. 

Soc,  1898,  XVII,  857. 

An  Outline  of  some  of  the  Medical  Uses  of  the  Roentgen  Light.     Am.  J. 

M.  Sc,  1899,  CXVII,  675. 

Observations  on  Pneumohydrothorax  and  Pneumothorax.     Med.  &  Surg. 

Reports  Bost.  City  Hosp.,  1899,  10  s.,  191. 

Roentgen  Ray  Examinations  in  Incipient  Pulmonary  Tuberculosis.     Bost. 

M.&S.  J.,  1899,  CXLI,  196. 

X-ray  Examinations  an  Aid  in  the  Early  Diagnosis  of  Pulmonary  Tuber- 

culosis.    Bost.  M.  &  S.  J.,  1899,  CXL,  513. 

X-ray  Examinations  of  the  Chest  as  illustrated  by  Two  Cases  of  Pneumo- 

hydrothorax and  Two  of  Pneumothorax.     Phila.  M.  J.,  1899,  IV,  575. 

Roentgen  Ray  Examinations  in  Diseases  of  the  Thorax.     Yale  M.  J.,  1900, 

VI,  233. 

X-ray  Examinations  in  Diseases  of  the  Chest.     Phila.  M.  J.,  1900,  V,  1 1. 

Note  on  X-ray  Examinations  of  the  Lungs.     Bost.  M.  &  S.  J.,  1900,  CXLI  I, 

555- 

The  X-rays  in  Medicine.     Allbutt  &  Rolleston's  System  of  Med.,  London, 

1905,  2d  ed.,  I,  473. 

Methods  for  determining  the  Density  of  Various  Parts  of  the  Body,  especially 

the  Lungs,  by  Means  of  the  X-rays.     Bost.  M.  &  S.  J.,  1906,  CLV,  185. 

The  Use  of  X-ray  Examinations  in  Pulmonary  Tuberculosis.     Bost.  M.  & 

S.  J.,  1907,  CLVIi,  850. 
Williams,   H.    The  Climatic  Treatment  of  Phthisis.     Bost.  M.  &  S.  J.,   1885, 
CXIII,  313. 


220  TUBERCULOSIS  IN   MASSACHUSETTS. 

Williams,   Mrs.    R.   P.    Can  Consumption  be  Cured?     A  State's   Experiment. 

N.  Eng.  Magazine,  May,  1901. 
Winchester,  J.   F.     Diagnosis  and   Prevention  of   Bovine  Tuberculosis.     Bost. 

M.  &  S.  J.,  1894,  CXXXI,  526. 
WoLBACH,  S.  B.,  and  Ernst,  H.  C.     Observations  on  the  Morphology  of  Bacillus 

Tuberculosis  from  Human  and  Bovine  Sources.     J.  M.  Research,  1903, 

X,3>3- 

Experiments   with    Tuberculins    made    from    Human    and    Bovine 

Tubercle  Bacilli.     J.  M.  Research,  1904,  XII,  295. 

Worcester,  A.  The  Treatment  of  Tuberculosis  with  Tuberculin  and  its  Deriva- 
tives.    Bost.  M.  &  S.  J.,  1896,  CXXXV,  177. 

Young,  J.  H.  A  Case  of  Acquired  Dextrocardia  associated  with  Advanced  Phthisis. 
Bost.  M.  &  S.  J..  1907,  CLVII,  791. 


APPENDIX.  221 


Massachusetts   committee   of   the   inter. 
NATIONAL  Tuberculosis  congress, 

Arthur  T.  Cabot,  M.D., Boston,  Chairman. 
John  B.  Hawes,  2d,  M.D.,  Boston,  Secretary. 
J.  F.  AUeyne  Adams,  M.D.,  Pittsfield. 
Charles  H.  Adams,  Boston. 
Carl  A.  Allen,  M.D.,  Holyoke. 
Edward  A.  Andrews,  Cambridge. 
P.  Challis  Bartlett,  M.D.,  Rutland. 
Albert  M.  Belden,  M.D.,  Northampton. 
Vincent  Y.  Bowditch,  M.D.,  Boston. 
John  T.  Bottomley,  M.D.,  Boston. 
Edward  H.  Bradford,  M.D.,  Boston. 
Jeffrey  R.  Brackett,  M.D.,  Boston. 
Wilford  G.  Brown,  M.D.,  Plymouth. 
Herbert  L.  Burrell,  M.D.,  Boston. 
Richard  C.  Cabot,  M.D.,  Boston. 
Charles  G.  Carleton,  M.D.,  Lawrence. 
H.  Lincoln  Chase,  M.D.,  Brookline. 
Herbert  C.  Clapp,  M.D.,  Boston. 
Israel  J.  Clarke,  M.D.,  Haverhill. 
William  T.  Councilman,  M.D.,  Boston. 
Simon  F.  Cox,  M.D.,  Boston. 
John  W.  Cram,  M.D.,  Colrain. 
Alvah  Crocker,  Fitchburg. 
Eugene  A.  Darling,  M.D.,  Cambridge. 
Hon.  William  L.  Douglas,  Brockton. 
Samuel  H.  Durgin,  M.D.,  Boston. 
Richard  Dutton,  M.D.,  Wakefield. 


222  TUBERCULOSIS    IN    MASSACHUSETTS. 

Herbert  C.  Emerson,  M.D.,  Springfield. 
Ernest  B.  Emerson,  M.D.,  Tewksbury. 
Harold  C.  Ernst,  M.D.,  Boston. 
John  W.  Farlow,  M.D.,  Boston. 
Reginald  H.  Fitz,  M.D.,  Boston. 
Cleaveland  Floyd,  M.D.,  Brookline. 
Mrs.  Lilias  Folger,  Medford. 
Langdon  Frothingham,  M.D.,  Boston. 
Miss  Emily  C.  Fisher,  Norwood. 
George  W.  Gay,  M.D.,  Boston. 
Albert  C.  Getchell,  M.D.,  Worcester. 
Joel  E.  Goldthwait,  M.D.,  Boston. 
Walter  A.  Griffin,  M.D.,  Sharon. 
Charles  Harrington,  M.D.,  Boston. 
Thomas  F.  Harrington,  M.D.,  Boston. 
Henry  B.  Hart,  M.D.,  East  Dennis. 
Ashton  E.  Hemphill,  Holyoke. 
Frederick  L.  Hills,  M.D.,  Rutland. 
Henry  Jackson,  M.D.,  Boston. 
Fred  R.  Jouett,  M.D.,  Cambridge. 
Elliott  P.  Joslin,  M.D.,  Boston. 
Mrs.  Mary  Morton  Kehew,  Boston. 
Frederick  I.  Knight,  M.D.,  Boston. 
Walter  E.  Kreusi,  Boston. 
Edwin  A.  Locke,  M.D.,  Boston. 
George  N.  Lapham,  M.D.,  Rutland. 
Robert  W.  Lovett,  M.D.,  Boston. 
Edward  F.  McSweeney,  Boston. 
Ernest  P.  Miller,  M.D.,  Fitchburg. 
Charles  S.  Millet,  M.D.,  Brockton. 
James  J.  Minot,  M.D.,  Boston. 
John  L.  Morse,  M.D.,  Boston. 


f 


APPENDIX.  223 

John  H.  Nichols,  M.D.,  Tewksbury. 
Edward  O.  Otis,  M.D.,  Boston. 
Austin  Peters,  M.D.,  Boston. 
Joas  C.  De  S.  Pitta,  M.D.,  New  Bedford. 
Joseph  H.  Pratt,  M.D.,  Boston. 
Charles  A.  Pratt,  M.D.,  New  Bedford. 
Silas  D.  Presbrey,  M.D.,  Taunton. 
Frederick  B.  Percy,  M.D.,  Brookline. 
George  L.  Rice,  M.D.,  North  Adams. 
Frederick  J.  Ripley,  M.D.,  Brockton. 
Maurice  H.  Richardson,  M.D.,  Boston. 
Thomas  M.  Rotch,  M.D.,  Boston. 
George  L.  Richards,  M.D.,  Fall  River. 
Prof.  William  T.  Sedgwick,  Boston. 
Charles  E.  Simpson,  M.D.,  Lowell. 
Theobald  Smith,  M.D.,  Brookline. 
Jeremiah  Smith,  Jr.,  Boston. 
Arthur  K.  Stone,  M.D.,  Boston. 
Frederick  C.  Shattuck,  M.D.,  Boston. 
George  B.  Shattuck,  M.D.,  Boston. 
David  Townsend,  M.D.,  Boston. 
Mrs.  C.  H.  Thomas,  Cambridge. 
Henry  P.  Walcott,  M.D.,  Cambridge. 
J.  Collins  Warren,  M.D.,  Boston. 
John  F.  Welch,  M.D.,  Quincy.   , 
Arthur  H.  Wentworth,  M.D.,  Boston. 
Frank  G.  Wheatley,  M.D.,  North  Abington. 
Francis  H.  Williams,  M.D.,  Boston. 
Mrs.  Rufus  P.  Williams,  North  Cambridge. 
Alfred  Worcester,  M.D.,  Waltham. 
William  H.  Watters,  M.D.,  Boston. 


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